Downshaw Lodge

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.

We identified a breach of legal regulations.

People’s individual needs were not fully assessed and planned for. Plans were not personalised or reviewed and updated to fully reflect people’s current and changing needs. There was little evidence to show people and those important to them had been involved in decisions about their care and treatment. Safeguards to uphold and protect people’s right needed improving.

People’s relatives said staff monitored their family members health and sought advice when needed. The service worked in partnership with relevant agencies to ensure guidance and support was provided in specific areas of care and support, so people’s health and well-being was maintained.

Areas of staff training was provided to help promote best practice. This included topics such as fluids and nutrition, dysphasia, pressure ulcer prevention and falls prevention. It was recognised that people’s records needed to be improved to better evidence clinical oversight by the nursing team.

Relevant servicing and checks of the environment and equipment had been completed. Action was outstanding in relation to fire safety and further improvements were needed to enhance the standard of accommodation provided to people.

We identified a breach of legal regulation.

From our observations, people’s experiences varied in the care they received. Whilst some interactions between people and staff were kind and caring, we also saw people were not always cared for in a dignified way or treated with respect.

People were not always supported to make decisions about their care. Staff did not always communicate with people, ask their permission to give care or explain what they were doing.

Staff told us they enjoyed their job, knew people well and how to support them. Staff described how they encouraged people to be as independent as possible.

People's care plans needed expanding upon to reflect how staff promoted their independence and social inclusion both in home and local community.

People and those important to them were not involved in the development of their care records, reflecting their individual needs, wishes and preferences, including how they wished to be cared for at the end of their life. Information was not provided in an accessible format such as different languages and print so people understood information held about them.

Opportunities to seek people views about the service and their experiences were needed to help identify and drive improvements.

We identified a breach of the legal regulations.

Since 2022 administrators have been responsible for the management of the service. Further management changes were being made following the departure of the registered manager.

Governance systems were in place however these were not sufficiently robust to address areas of improvement identified by managers and those identified during this assessment. The service also identifies as a complex dementia care service however this is not reflective of the service provided. It was recognised the service needed a period of stability so systems providing clear management and oversight of the service could be implemented and embedded.

Managers were working closely with relevant agencies to make the necessary improvements.