Updated 19 June 2025
Date of Inspection: 2 July to 11 July 2025. The inspection was unannounced and was undertaken in response to concerns raised about the service, specifically regarding care and support, infection prevention and control, governance processes, record keeping, the condition of the premises, and recruitment and training practices.
During the inspection, we found evidence indicating that people were at risk of harm due to these issues. As part of our inspection, we assessed all relevant quality statements across the key questions. We identified 8 breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014:
- Regulation 11, Need for consent
- Regulation 12, Safe care and treatment
- Regulation 13, Safeguarding
- Regulation 14, Meeting nutritional and hydration needs
- Regulation 15, Premises and equipment
- Regulation 17, Good governance
- Regulation 18, Staffing
- Regulation 19, Fit and proper persons employed
We have combined the scores for these areas with scores from the last inspection to give the rating for this assessment. The service has been rated inadequate following this assessment.
The service was in organisational safeguarding measures at the time of this inspection. This meant the local authority was monitoring the service and supporting them to ensure the correct procedures were in place to keep people safe. Sufficient action had not been observed by the local authority to enable the service to be moved out of these measures.
Howlish Hall Residential Care Home is a residential care home that provides personal care for up to 40 older people, including individuals living with dementia. The service also supports people with mental health conditions. At the time of the inspection, 27 people were living at the service and receiving the regulated activity of accommodation for persons who require nursing or personal care.
The inspection was carried out by 2 inspectors and a regulatory officer. During the inspection we observed care practices and read a variety of documents in relation to the quality and safety of the service. This included care plans, medicine records and staff recruitment records. We also spoke with people who use the service, relatives, health and social care professionals and staff.
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. However, the registered manager had recently left and there was a new manager in post who supported the inspection.
The provider of the service failed to ensure that effective systems were in place for assessing and monitoring risks to people’s personal safety.
The provider of the service failed to ensure people were protected from the risk of harm and abuse. Staff did not consistently identify safeguarding concerns and report them to the appropriate internal and external agencies.
The provider of the service failed to ensure that effective systems were in place for assessing the risk of preventing, detecting and controlling the spread of infections.
The provider did not make sure effective systems were in place to ensure the service was working within the principles of The Mental Capacity Act 2005. Where it was deemed people did not have the capacity to consent, robust assessments were not in place to determine if people had capacity. Failure to implement appropriate capacity assessments puts individuals at risk of decisions being made without appropriate legal or ethical safeguards.
The provider did not consistently ensure there were enough qualified, skilled, and experienced staff to meet the needs of people using the service. Staff did not always receive effective support, supervision, or opportunities for development. Although the service used a training matrix to monitor staff training, it was unclear which staff members were up to date with their training. Additionally, some staff reported feeling unsupported by management.
The provider failed to ensure the premises and equipment were properly maintained. Failure to properly maintain these or to take action without delay when shortfalls were identified placed people at risk of harm.
The provider failed to ensure robust systems were in place to assess, monitor and improve the quality and safety of the service. Whilst the manager carried out audits and checks; these had not identified the shortfalls we found during this inspection.
This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.