Donwell House

Updated 27 August 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

One inspector carried out this inspection.

Service and service type

Donwell House Care Home 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 announced. We gave 24 hours' notice that the inspection would be taking place. This ensured we were able to work alongside the manager to identify any potential risks associated with the coronavirus pandemic and put measures in place to manage them.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. This included information about incidents the provider must notify us about. We sought feedback from the local authority professionals who work with the service. The provider was not asked to submit a provider information return prior to our inspection. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make or have made since the last inspection. We accounted for this when we inspected the service and made the judgements identified in this report. We used all of this information to plan our inspection.

During the inspection

We did not speak with people directly to seek their views on the service, due to the coronavirus pandemic. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We spoke with three members of staff: the registered manager, the deputy manager and the activities coordinator/family liaison officer.

We reviewed a range of records. This included four people’s care records, rotas, activities planning and outcomes, menus, compliments and complaints. We reviewed a variety of records related to the management and quality assurance of the service, including policies, audits and quality assurance visits by the provider.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at the home action plan and policies and procedures. We contacted 10 relatives and four staff via telephone to gain their views. We contacted four external health and social care professionals to gain their views, and one community group who worked closely with the service.

Updated 27 August 2020

About the service

Donwell House is a care home providing personal and nursing care for up to 63 people, some of whom are living with dementia. At the time of the inspection there were 52 people living at the home. Bedrooms are situated on two floors with people having access to communal lounges and dining areas.

People’s experience of using this service and what we found.

At the last inspection we found improvements were required to ensure people received person-centred care. At this inspection improvements to care planning and reviews had been sustained, with people’s individualities and interests factored in to care planning and activities provision. Activities were meaningful and had a positive impact on people’s wellbeing. Sufficient improvement had been made at this inspection and the provider was no longer in breach of regulation 9.

At the last inspection of the service the provider had failed to ensure governance systems were sufficiently effective to monitor and improve the quality and safety of the service. Since the last inspection the registered manager and leadership team had made a range of improvements. Quality assurance and audit processes were robust and action plans adhered to. Strong links had been made with community groups and interactions with external health and social care teams were positive, with consistently strong feedback. Sufficient improvement had been made at this inspection and the provider was no longer in breach of regulation 17.

At the last inspection we found improvements were required regarding meal choices and standards. Improvements to menu planning, meal preparation and inclusion of people to value and respect their choices had been implemented since the last inspection. Feedback was consistently positive regarding the standard and choice of meals and we observed positive and patient interactions during lunchtime. Sufficient improvement had been made at this inspection.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The service was rated requires improvement at the last inspection (published 30 September 2019). Following the inspection, the provider submitted an action plan to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We completed this focused inspection to make sure they had followed their action plan and to confirm they now met legal requirements. This report covers our findings in relation to those three key domains: effective, responsive and well-led.

As part of CQC’s response to the coronavirus pandemic we are also conducting a thematic review of infection control and prevention measures in care homes. The Safe domain also therefore contains information around assurances we gained from the registered manager regarding infection control and prevention.

The ratings from the previous comprehensive inspection for those key domains not looked at during this inspection were used in calculating the overall rating for this inspection. The overall rating for the service therefore has improved to good based on the findings at this inspection.

You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Donwell House on our website at www.cqc.org.uk

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our inspection programme. If we receive any concerning information we may inspect sooner.