Archived: Downshaw Lodge

Updated 29 April 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service and to provide a rating for the service under the Care Act 2014.

This inspection took place on 7 and 8 February 2017 and was carried out by two adult social care inspectors and one Specialist Advisor on day one, and one social care inspector on day two. The Specialist Advisor was a nurse with knowledge and experience of medicines management.

Downshaw Lodge is situated in the Ashton-under-Lyne area of Tameside in Greater Manchester. The home provides care, support and accommodation for up to 45 older males who require personal care with nursing.

Before we visited the home, we checked the information we held about the service including notifications sent to us by the provider. Statutory notifications are information the provider is legally required to send to us about significant events. We also reviewed the Provider Information Return (PIR) that the provider had completed in December 2016. This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. At a recent meeting with the Commissioners from the local authority we were told that they were happy with the improvements being made at Downshaw Lodge by the new manager and staff team.

The overall rating for this service following the last inspection was found to be ‘Requires Improvement’. This inspection was carried out to see if the required improvements had been made.

During this inspection we spoke with the manager, the deputy manager, one senior care assistant, three care assistants and four people who used the service.

We reviewed a variety of records, including the care files of four people, medication administration records (MARs) of ten people, two staff recruitment files, staff training records, staff supervision records, records of servicing and maintenance of equipment and premises and records of quality audits.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

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Updated 29 April 2017

This inspection was carried out over two days on 7 and 8 February 2017 and the first day was unannounced.

Downshaw Lodge is a purpose built, two storey nursing home. The service provides support for up to 45 people who are living with dementia or have mental health needs. The service is a single sex provision due to the complex needs of the people who use the service.

At the time of our inspection 30 people were residing in the home.

The service was last inspected in May 2016 at which time we found four breaches of four of the regulations of the Health and Social Care Act 2008 (Regulated Activities) 2014. We also made three recommendations that related to developing dementia friendly environments, ensuring systems support people’s dietary and nutritional needs to be met, and ensuring continuity of activity provision. This inspection was carried out to check sufficient improvements had been made to the service.

There was a manager in post at the time of our inspection. This person was not yet registered with the Care Quality Commission (CQC) but evidence was available to demonstrate that their application was being processed by CQC at the time of our visit. 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.

Staff understood their roles and responsibilities in keeping people safe and protecting them from harm.

People who spoke with us told us they felt the care and support they received was good and safe.

We found that medicines were managed safely and people received their medicines as prescribed by their doctor or other prescriber.

Sufficient numbers of appropriately trained care staff and qualified nursing staff were available to support people and help meet their assessed needs.

Staff meetings and formal staff supervision had been taking place on a regular basis since the last inspection of the service and this was confirmed by staff we spoke with and records seen.

People told us they liked the food offered. We saw meals were fresh and looked and smelled appetising. People were offered choices of various alternative foods and beverages and we observed that the atmosphere over the mealtimes were calm, sociable and unhurried.

We saw evidence that fluid and dietary intake was being recorded after meals to accurately record what people were eating and drinking. Any advice from healthcare professionals such as nutritionists was being recorded in relevant documentation.

Each person using the service had an up-to-date care plan, risk assessments and other associated documentation in place.

The range of organised activities for people to participate in had improved since our last inspection of the service. The service employed an activity co-ordinator who actively engaged with people individually or in groups.

We saw that the service had a written complaints policy which was included in the service user guide and was also displayed in the main hallway of the home.

Where people who used the service lacked capacity to consent to care and treatment the appropriate steps were taken to protect their rights.

Systems were in place to monitor the quality of service and to identify where improvements to the quality of care could be made.

At the last inspection in May 2016, we rated the well-led domain as ‘requires improvement’ as we found the management of the service was not, at that time, well-led and staff lacked clear management leadership. At this inspection we found the provider had taken action and was now meeting legal requirements.