Downshaw Lodge

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We identified 5 breaches of the legal regulations. Safeguarding concerns were being addressed with the local authority who were currently monitoring the service. Applications to deprive people of their liberty were not submitted or renewed in a time manner ensuring lawful authorisations were in place. Areas of risk to people’s health and well-being were assessed and planned for. Assessments were not always accurate and kept up to date. Additional monitoring to help identify changing needs needed to be improved. People’s prescribed medicines were not managed in a consistent and safe way. Adequate numbers of staff were available to support people’s needs. A programme of staff training was provided. This could be enhanced with further specialist and clinical training relevant to the needs of people. Relevant servicing and checks of the environment and equipment had been completed. Areas of work and staff training were still required in relation to fire safety.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and their relatives felt some staff were more skilled and competent in carrying out their role and responsibilities than others. All were aware of the issues within the home and had been kept informed of the management changes and areas of work planned to make improvements across the service.

The regional manager acting on behalf of the Administrators told us they had developed an action plan identifying areas of improvement across the service. This included areas of learning following recent feedback from the coroner. The regional manager was also meeting regularly with the local authority to review progress made to address current concerns. Staff spoken with confirmed concerns had been shared with them in a recent staff meeting. Discussions had included areas of learning, and the action required to make the necessary improvements. Staff said they had not routinely received formal supervision and support. We were told these would be introduced by the new manager helping to identify and support staff learning and development.

Accidents and incidents were monitored, helping to identify any themes and patterns. Following a report from the coroner, recent issues and action required had been shared with the staff team. A joint handover meeting had been introduced so the nurse on duty had better oversight of people’s needs. However, records to evidence this needed further improvement. In addition, formal systems to monitor and support staff learning and development were needed so staff were working in a consistent and effective way. The interim manager was undertaking ‘daily walkaround’, this included observations of staff and a review of records. Any shortfalls were identified and acted upon. In relation to management and oversight. More robust audits and checks were needed to help identify areas of improvement and learning across all areas, including those areas found during our assessment of the service.

People felt supported by the staff team. Staff worked with other agencies where additional advice and support was needed to meet the current and changing needs of people. People’s records showed advice, and support was accessed from other healthcare professional where needs had changed, or areas of risk identified. People’s relatives said they were kept informed of people’s changing needs. We were told, “There are some very caring staff there. [Staff] are brilliant and keep an eye on him for me” and “Any issues and they [staff] will phone me straight away. I think it is a caring place.”

Senior staff spoke about how they liaised with other agencies so that people’s needs were safely met. One staff member spoke about a person’s discharge from hospital being delayed allowing for relevant assessments to be completed and appropriate arrangements put in place to meet their changing needs. Staff said they had good support from the local GP who made a weekly call to review any concerns about people, as well as home visits where necessary. In addition, staff said they were able to seek advice and support from ‘digital health’. Staff said they were kept informed about people’s changing needs, new admissions, or people returning from hospital through the shift handovers held each day.

The service worked in partnership with other agencies to ensure people transferring between services were supported safely and appropriately.

The service had a service user guide which outlined the process followed when moving into the home. Social work or nursing assessments would be sought in addition to the home completing an initial assessment. This information helped to determine if the persons needs could be met. The service worked closely with a range of health and social care providers. In addition to the GP, people were supported by other agencies such as the community mental health team, community nurses, speech and language therapists, dietician, podiatry, optician, and dentist. People’s records included a hospital passport. However, these were not always completed or in sufficient detail. A hospital passport documents information about the person and their health needs. It also has other useful information, such as people’s interests, likes, dislikes, how they communicate and any reasonable adjustments that might be needed. These records help to promote safe and consistent support when transitioning between services.

People said they were generally ‘okay’ and felt supported by the staff team. People told us, “I’ve been here about three years. To be honest, it’s okay. The staff are very good and are there if I need them” and “I find it okay here. The staff aren’t so bad.” Whilst issues and concerns about people had been shared with the local authority and CQC, systems to ensure people’s rights were protected were not effective.

Staff said they understood their responsibilities in safeguarding people from harm and had completed e-learning training. However, staff were not fully aware which people were subject to a deprivation of liberty safeguarding and what this meant for the person. Two staff spoken with raised a concern about one person whose movement in and around the home was restricted as necessary equipment was not in place. We were told this person was confined to their bedroom and only hoisted to and from their bed or armchair. Due to this restriction, the person was unable to join others in the communal areas, have their meal in the dining room or take part in activities both internally and within the community. This was to be addressed by managers. The regional manager told us they were working closely with the local authority to address the recent safeguarding concerns. Any action required would be shared with the staff team to help keep people safe.

Staff skills varied in relation to their confidence and competence when supporting people. Some staff needed further training and support so they could support people in a safe and effective way.

Policy and Procedures were in place with regards to Safeguarding Adults, the Mental Capacity Act (MCA), Deprivation of Liberty Safeguards (DoLS) and Equality and Human Rights. This was supported by training in each of these areas. A review of training records showed a completion rate of 90%. However, we found policies and procedure were not always followed in practice, particularly in relation to DoLS. Internal procedures stated managers were to ensure DoLS applications were submitted to the local authority in a timely manner including those where the application had expired but the deprivation still applies. Information provided showed 3 authorisations were out of date and there had been considerable delays (up to 16 months) in submitting renewal applications for 11 people. This did not demonstrate lawful restrictions were in place, so people’s rights were not protected. A review of care records showed where people lacked the mental capacity to make decisions for themselves, these had been made in their best interest. However, we found information was limited and did not evidence ‘best interest’ decisions had been made in partnership with people’s relatives or other professionals involved in their care, so the persons wishes and feelings were fully considered. Managers were aware of their responsibilities in reporting events within the home to CQC, as required by law. Information and concerns were also shared with the local authority and currently monitored through the multi-agency concerns meeting held on a bi-monthly basis. Our findings demonstrated a breach of regulation 13 regarding safeguarding service users from abuse and improper treatment.

We found little evidence that people and those important to them had been actively involved in the development of their support plans. Where necessary we did find that referrals for advice and support had been sought to help minimise potential risks to people. Not everyone was able to ask for assistance when needed. Sensor equipment was in place to alert staff in when people needed help. A call bell system was available for those people able to ring for assistance. However, one person told us, “I don’t have a buzzer though. I don’t get help unless someone is passing, it’s a bit poor really.”

The regional manager acknowledged there were shortfalls in people’s records. A business improvement plan had been drawn up and regular discussions were being held with staff about the areas of improvement required. Staff spoken with had worked at the home for some time and knew people well. Staff confirmed they had received training in areas of risk and health and safety, and these were updated annually.

Whilst observing staff, they appeared to of had the correct moving and handling training. Staff confidently assisted people whilst keeping up conversation and explaining the manoeuvre to the individual being moved.

People’s care records did not evidence potential risks to their health and well-being were appropriately assessed, monitored, and planned for. This included areas such as weight loss, food and fluid intake, and pressure care. Assessments did not always provide sufficient detail to guide staff and were not always accurate and update. We also found gaps in monitoring records. Records showed some people required close observations, as part of their risk management plan and DoLS authorisation. However, a number of authorisations had lapse, and timely applications had not been made for their renewal. As part of the governance system, audit and checks had been completed in areas of risk to people. These included skin integrity and pressure care, accidents and incidents and weight analysis. Checks included a review of the previous month, and any new concerns and actions required. However, checks had not been made to ensure this information had been transferred to people’s records along with action taken to mitigate risk. Equipment was in place to aid people’s mobility and safety. Items included wheelchairs, walking frames, sensor mats, pressure aids, call bells and profiling beds. A review of records showed relevant checks had been completed to ensure they were in good working order. Maintenance staff were responsible for completing a number of health and safety checks on a weekly or monthly basis. These included areas such as fire safety, emergency lighting and water temperatures. An external fire risk assessment had been completed in January 2024. Several recommendations were made to improve fire safety. We found some areas had yet to be addressed. Our findings demonstrated a breach of regulation 12 regarding safe care and treatment.

People we spoke with during the inspection did not make any comments about the home environment. We found people were not provided with a good standard of accommodation, which was dementia friendly helping to promote and encourage their independence.

The regional manager recognised improvements were needed to the physical environment. We were told they had submitted a request to the administrators for the finances to be released in order to complete the work. The maintenance staff outlined their role and responsibilities. We were shown tasks completed were recorded electronically and monitored by managers to ensure these were completed regularly within the required time. Checks undertaken included fire safety, water temperatures, window restrictors, emergency lighting and call bells. Maintenance staff said they were also responsible for basic repairs and redecoration of the home and that contractors were utilised for specific areas of maintenance work. The maintenance staff told us, “This is the best job I have ever had. It’s a good staff team and the generally staff morale is good.”

Accommodation was spacious, with aids and adaptations. However considerable work was required to improve and enhance the appearance of the home. From our observations we found the décor throughout the home was poor, in some rooms there was a malodour and there was damage to the ceiling in several areas due to flooding. Communal rooms were not homely, and some replacement furniture was required. We saw maintenance staff were repainting the hallways on the ground floor. There were plans for them to complete work throughout the home. We found the kitchen clean and tidy, with separate food storage available. There was also a designated laundry. This room was excessively hot and had no ventilation or air conditioning.

Relevant internal and external safety checks of the environment had been completed to ensure the premises and equipment were kept safe. The service had a contingency plan. This detailed a clear emergency evacuation plan following an incident or systems failure and included individual personal emergency evacuation plans. A fire risk assessment had been completed in January 2024. Actions were identified. This included 1 area assessed as high risk requiring immediate action and 6 areas assessed as medium risk requiring action within 10 weeks. Four of these actions remained outstanding including fire simulated evacuation training, which only 50% of staff had completed. A review of training records showed no further progress had been made in this area. Further work was required to enhance the standard of accommodation and furnishings providing people with a comfortable, well maintained home. As part of the homes business improvement plan areas of redecoration and refurbishment had been identified, as well as signage and equipment creating a more ‘dementia friendly’ environment. Financial resources had been requested, once agreed work would be scheduled for completion. Our findings demonstrated a breach of regulation 15 regarding premises and equipment.

People liked the staff but felt they had mixed skills and abilities. This too was felt by some members of the team and observed during the assessment. People and their relatives told us they liked the staff and felt sufficient numbers of staff were available. We were told, “The staff aren’t so bad. There are usually one or two around most of the time,” “The staff are fabulous. Nothing is too much trouble, and they come straight away if he needs them” and “They could do with more staff around certain times though.” We received a mixed response about staff skills and abilities. We found support, particularly on the 1st floor, was task focused with little interaction and engagement with people at times. When asked if staff were well trained one person said, “Most are to be honest, but odd ones just go through the motions and take the money.” People’s relatives also told us, “Some staff have been here since he moved in and are very good with him whilst others just stand around” and “The staff seem to be good at their jobs and go out of their way for [relative].”

Staffing arrangements and clinical oversight were regular topics of discussion with the local authority. The regional manager said there had been recent changes within the team. Where necessary staff performance had been reviewed and further nursing staff had recently been employed to help reduce the use of agency staff. In addition, further changes had been made to the shift handover meetings. These were now held jointly, involving the nurse and care teams from both floors, therefore providing better clinical oversight and management of people’s support. The regional manager said they had recently held a team meeting to provide staff with an update about changes within the team including the appointment of a new manager. It was anticipated once they commenced employment, systems to further support and develop the staff team would be implemented. Staff spoken with confirmed they completed a range of e-learning training. However, acknowledged that formal supervisions had not been held and team meetings were infrequent. Staff said the team had been fairly stable with a number of staff having worked at the home for many years. Staff felt they worked well together supported each other. Although some staff also felt competence and confidence differed across the team. One staff member told us, “It feels there are differences in skills and competency across the team, feels some staff do and some don’t.” Staff spoke about the support offered to people living at the home. We were told some people displayed distressed behaviours and at times could be violent and aggressive. Whilst Positive Behavioural Support (PBS) e-learning training had been provided, there had been no further practical training to support staff with de-escalation techniques when people became distressed, to check staff understanding and staff practice.

Whilst some staff were seen to be proactive and engaged with people living at the home, others were more task focused and did not provide meaningful engagement.

Systems to support and develop the staff team needed improving. There was a programme of e-learning training provided. However, this did not incorporate clinical updates for nursing staff or comprehensive training in dementia care and managing distress behaviours, considering the complex care provided at the home. In addition, formal supervision for both care and nursing staff were not undertaken or regular team meetings. Relevant recruitment checks were completed including those provided by the agency. Additional checks were also completed in relation to nursing staff to check their registration was up to date and valid. Further recruitment had been taken place to minimise the use of agency nursing staff. The service used a dependency tool to determine staffing levels. A review of rotas showed ratios calculated were provided. These were checked by the manager during the morning ‘walk around’. However, these did not reflect how staff had been deployed throughout the home to evidence sufficient numbers available on each floor. We were told the nurse on duty each morning would allocate which areas of the home staff were to work. Our findings demonstrated a breach of regulation 18 regarding staffing.

Designated domestic and laundry staff were provided to help ensure hygiene standards were maintained throughout the home and people were provided with clean laundered clothes.

Staff said they had access to policies and procedures in safe infection control procedures. Staff were provided with personal protective equipment and were seen wearing gloves and aprons when carrying out specific tasks. Domestic and laundry staff spoken to had worked at the home for many years and were clear about their responsibilities. We found the laundry room was extremely hot. Laundry staff said there was no ventilation, providing a difficult working environment.

Work had been completed to improve hygiene standards throughout the home by a dedicated team.

The local authority health protection team had completed an inspection of the service. Areas of improvement had been identified and all action taken to improve hygiene standards within the home. Health protection staff had also attended the home to deliver the fundamentals of Infection Prevention and Control training, which had been well attended. The service user guide outlined the laundry and housekeeping services provided. There were designated domestic and laundry staff available throughout the week. Tasks completed were recorded and quarterly audits were to be carried. These had not been completed for May and August.

Care plans and other written guidance did not always include up-to-date and personalised information to support people with their prescribed medicines. This included information about the covert (hidden) administration of medicines and the use of ‘when required’ medicines. For example, one person’s diabetes care plan had not been updated following a change in insulin and was not followed in practice. The homes best interest decision making paperwork for the covert (hidden) administration of medicines was incomplete for one person, and there was no record of pharmacist advice being sought to help ensure this was done safely. The agency nurse administering medicines did not administer medicines in accordance with the home’s policy, increasing the risk of errors. However, policy was followed in another area of the home. The nurse-in-charge confirmed that medicines processes were explained to agency staff, but this was not recorded.

Staff spoke positively about the home’s medicines training and the competency assessments that were completed before taking responsibility for administering people’s medicines. Staff we spoke with explained how they prepared prescribed thickeners safely. Managers completed regular medicines audits; these had identified some shortfalls for example with fridge temperature recording but had not identified the wider concerns related to medicines management we found during the inspection.

There was a medicines policy in place. However, we were not assured that staff always followed it when recording medicines administration. This meant that in one part of the home, medicines could not always be accounted for. Similarly, the consistency of thickened drinks was not recorded when they were made up, and we could not always confirm the current instructions. The medicine fridge temperatures were recorded, but there was no evidence that action had been taken when the temperature was too low, staff were also unable to reset the thermometer Our findings demonstrated a breach of regulation 12 regarding safe care and treatment.