Downham Grange

Inspectors found that regular checks of fire safety equipment and legionella water safety were being completed.

“Regular checks of fire safety equipment, and legionella water safety checks were being completed.” from the report

The home was working within the principles of the Mental Capacity Act, and required legal authorisations were in place where people were deprived of their liberty.

“We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty.” from the report

People and relatives said they felt able to raise concerns. Inspectors also found that people and relatives were involved in developing care records.

“People and relatives told us they felt comfortable raising concerns or complaints with staff, and these would be responded to appropriately.” from the report

Inspectors saw staff respond to people who were upset or needed reassurance. Staff were also observed using reflective practice after incidents.

“We observed staff to be responsive to people for example if they were upset or needing reassurance.” from the report

Medicines were sometimes out of stock or not given as prescribed. Records for creams and patch medicines had gaps, some creams were out of date, and some creams were not stored securely.

“People did not always receive their medicines as prescribed.” from the report

Choking, pressure sore, diabetes, food and fluid risks were poorly managed. Some people could access items that might harm them, including denture tablets, creams and personal care products.

“People, including those living with dementia were able to have unsupervised access to items such as denture cleaning tablets, drink thickener, razors and personal care products were not stored securely to protect them from harm.” from the report

Some areas and equipment were visibly dirty. Inspectors saw unclean fingernails, malodour in some bedrooms and gaps in records for nail and teeth cleaning.

“People's basic care needs were not met.” from the report

The provider's audits had identified some concerns but had not led to effective action. Notifiable incidents were not consistently reported, and there was no registered manager in post.

“The systems and processes to assess, monitor and improve the quality and safety of the service were not established or operated effectively to maintain standards and drive improvement at the service.” from the report