Beech Haven
London, W5 · 0.4 km
ResidentialDementia
Rated 12 months agocare home
CQC report explained · a residential care home, run by Downhurst Residential Home
Downhurst Residential Home Limited
76 Castlebar Road, London, W5 2DD
Goodpublished 6 August 2024, 2 years ago
Rated Good: inspectors found the service performing well and meeting their expectations.
The latest report, explained
What inspectors found, October 2023
Downhurst Residential Home Limited is rated Requires Improvement and placed in special measures; medicines, safeguarding and management systems were not reliable enough.
This was an unannounced focused inspection on 6 June 2023. Inspectors checked whether the provider had acted on its previous improvement plan. They spoke with people, relatives and staff, and reviewed care plans, medicines records, recruitment files and staff supervision records.
There had been improvements in risk assessments, care planning and activities. Relatives said people were safe and well cared for. Inspectors also found enough staff, suitable recruitment checks and good infection control arrangements.
However, some medicines were not given as prescribed, medicines were sometimes unavailable, and records were not always accurate. A possible safeguarding incident was not referred to the local authority. The provider's audits did not reliably identify these problems or ensure lessons were learned.
The overall rating remained Requires Improvement. Safe improved from Inadequate to Requires Improvement, Responsive improved to Good, and Well-led fell from Requires Improvement to Inadequate. Effective and Caring were not inspected, so their previous ratings were used in the overall rating.
What inspectors praised
Improved care planning
Care plans included current support needs, preferences, communication needs and risk information. Staff could access them electronically.
“People's care plans reflected their support needs and identified how they wished their care needs to be provided.” from the report
Activities
The range of activities had improved, with an activities coordinator arranging exercises, singing, puzzles, hand massages and gardening-related activities.
“We saw the activities coordinator spending time with people in the lounge singing, supporting people with chair-based exercises, hand massages and completing puzzles.” from the report
People felt safe and welcomed
People and relatives said they felt safe and were happy with the care. Relatives also said they were welcomed when visiting.
“People we spoke with said they felt safe living at the home.” from the report
Infection control
Inspectors were assured about infection prevention, the use of protective equipment, safe visiting arrangements and the home's ability to manage infection risks.
“We were assured that the provider was using PPE effectively and safely.” from the report
What inspectors were concerned about
Medicines were not always safe
seriousSome medicines were given differently from the prescriber's directions. Medicines were also sometimes missing, and handwritten records did not always contain complete instructions.
“This meant people did not always receive medicines as prescribed.” from the report
Safeguarding procedure not followed
seriousAn incident between two people was not recognised as a possible safeguarding concern and was not referred to the local authority for investigation.
“This placed people at risk of harm.” from the report
Weak quality checks
seriousAudits did not identify important problems with medicines, safeguarding, incidents or falls. This meant leaders did not have a dependable picture of risks and needed improvements.
“The provider had not implemented a robust process to monitor the quality of the care being provided.” from the report
Improvements were not sustained
needs fixingThe provider had remained in breach of regulations 12 and 17 since April 2021, and the improvement work had not produced consistent compliance.
“The provider had not made and sustained improvements to the service to change the rating of the location following inspections.” from the report
Questions to ask them, based on this report
- 01What checks are now in place to make sure every medicine is given exactly as prescribed and that medicines do not run out?
- 02How will you identify and report incidents that may be safeguarding concerns to the local authority?
- 03What changes have you made to ensure lessons are recorded after falls, accidents and incidents?
- 04How will your audits check every relevant fall, medicines issue and safeguarding concern rather than only selected examples?
- 05What action plan was sent to the CQC, and what progress has been made since the warning notice?
This was a focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 7 October 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
The story over the years
Every inspection of Downhurst Residential Home Limited
8 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- October 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Inadequate
Read what inspectors found at Downhurst Residential Home Limited →
- December 2022Requires improvementup from InadequateSafe: InadequateResponsive: Requires improvementWell-led: Requires improvement
- July 2022Inadequatestayed InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- October 2021Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Inspected but not ratedResponsive: Inspected but not ratedWell-led: Inadequate
- April 2021Requires improvementdown from GoodSafe: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- October 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2017Goodstayed GoodSafe: Requires improvement
- July 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 7 December 2010.
Ratings and report dates from the Care Quality Commission. A service can also be visited without a new rating being published, so the timeline shows published inspections, not every contact the CQC has had with the service.
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