The Care Quality Commission (CQC) has dropped the rating for Downham Grange, a nursing home run by Kingsley Care Homes Limited, from requires improvement to inadequate following inspections in June and July and placed the service into special measures to protect people.
Downham Grange is a nursing home providing accommodation and personal care for up to 62 people. The inspection took place over two days and included an Expert by Experience – someone who has personal experience of using or caring for someone who uses this type of care home.
As well as Downham Grange’s overall rating dropping from requires improvement to inadequate, so have its ratings for how safe and well-led it is. Its ratings for how effective, caring and responsive were not looked at this time, so they remain good.
CQC has placed the service into special measures, which means it will be kept under close review and re-inspected to check on the progress of improvements.
Gill Hodgson-Reilly, CQC’s deputy director for the East of England, said:
“When we inspected Downham Grange we were concerned to find a home where health and hygiene were not prioritised. We found equipment, such as crash mats, wheelchairs, pressure cushions and items of furniture were visibly unclean, some people’s bedrooms had malodour, and some flooring and surfaces were damaged, impacting on the ability to keep these areas clean.
“Some people were not being protected from risk of harm, with items such as razors and denture cleaning tablets not securely stored in some of the rooms. This was of particular risk for those people living with dementia, who relied on the staff to maintain their safety. What food and drink people had consumed was not well recorded, which is a particular risk to people with diabetes who need to eat and drink regularly to stay healthy.
“We also found that people didn’t always get the medication they needed, with medicines running out and not being reordered and some creams out of date but still being used and there were gaps in recording medicine use. The home has since assured us they are working with GPs and pharmacies to resolve this issue.
“Although staff were responsive to people’s needs, the home was regularly understaffed, which was particularly concerning at nighttime where there was often one instead of two nurses available to deal with people’s complex medical needs.
“We are considering what further regulatory action to take to keep people safe and we will report on this when we are able to.”
Inspectors also found:
- People did not always receive support from suitably trained staff. New staff were not receiving thorough inductions and support
- As there was no registered manager at the time of the inspection, the provider should have been providing oversight of the service, which inspectors found lacking
- Some people had unclean fingernails, and there was a lack of records to show people’s nails or teeth were being regularly cleaned
- People with risks of developing pressure sores or at risk of chocking were poorly managed.
However:
- People and their relatives told us they felt safe living at the service. We saw staff were responsive to people, for example if they were upset or needing reassurance
- People were able to spend time with relatives and friends inside and outside of the service, as well as accessing the local community