Background to this inspection
Updated
7 April 2020
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.
Inspection team
The inspection team consisted of an inspector and assistant inspector.
Service and service type
Down Hall is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We reviewed information we had received about the service since the last inspection such as notifications, safeguarding concerns and information shared with us by the public. We sought feedback from the local authority as to their involvement with the service. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.
During the inspection
We spoke with six people who used the service and two relatives about their experience of the care provided. We spoke with ten staff including three care staff, a housekeeper, the cook, the activities coordinator, the deputy manager, registered manager and the owners. We talked with two professionals who regularly visited the service. We also used observation of people’s care to inform us about the level and quality of care provided.
We reviewed three people’s care files and four staff personnel files. A sample of the service’s quality assurance systems, medicines administration, staff support, and complaints and compliment records were also looked at.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records. We spoke with three relatives and two volunteers by phone and received email information from two professionals.
Updated
7 April 2020
About the service
Down Hall is a residential care home providing personal care for up to 38 people of all ages, some who may be living with dementia. There were 20 people living at the service at the time of the inspection. The accommodation is on two levels, with three units, Ash, Cedar and Oak.
People’s experience of using the service and what we found
People told us the management and staff were admirable and went the extra mile to provide outstanding personalised care. The service was exceptionally responsive and distinctive in how they involved people and the community together for mutual benefit. People's end of life care was individualised, comfortable, and dignified and people's families received empathy and understanding.
People were safe, and well cared for. There were systems in place to protect people from abuse and avoidable harm. Staff understood how to raise concerns and knew what to do to safeguard people.
Risks to people’s safety and wellbeing were assessed, recorded and monitored. People were protected by the prevention and control of infection. Lessons had been learned and improvements made as a result.
People received their medicines as prescribed and in a timely way.
Staff were provided with an induction to the service and training suitable for their role and responsibilities. They felt valued and supported by the management team and received formal supervision. Staff recruitment and employment practices and procedures were safe. There were enough members of staff to support people living at Down Hall.
People received enough food and drink to meet their needs and meals were of a good size and quality. People were supported to attend appointments and were referred to health and social care professionals and healthcare services for their ongoing health and wellbeing. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests. People had a clean and well decorated environment in which to live.
People were treated with care, kindness, and their dignity and privacy maintained. They were involved in their care and offered choice and support to be as independent as possible. Staff had a good rapport and relationship with the people they cared for and their families. Staff were aware of people’s changing needs through their care plan and effective communication within the service.
The service was very well-led and managed by an experienced manager. Quality assurance arrangements enabled the provider and registered manager to monitor the quality of the service provided, staff performance and health and safety of the building. Complaints were well managed and a record of compliments to capture the service’s achievements was maintained.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
This service was registered with us on 4 March 2019 and this is the first inspection.
Why we inspected
This was a planned inspection based on the previous rating.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.