This inspection took place on 13 and 16 November 2018 and was unannounced. The provider knew we would be returning for a second day but not when.
Howlish Hall is a ‘care home’. People in care homes receive accommodation and nursing or personal care as 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 is registered for 40 people and at the time of inspection there were 31 people living at the service.
A registered manager was in post at the time of the inspection visit, although they were absent on both days. They were registered with the Care Quality Commission in July 2013. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
The last inspection of the service was carried out in November 2017 and was rated requires improvement. We found that the service was not meeting all the requirements of Health and Social Care Act 2008 and associated Regulations. We found concerns relating to their emergency policies and procedures not always being followed, records were not effective at monitoring and recording staff training and the provider’s systems for assessing, monitoring and improving standards at the service were ineffective. Following this inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions to at least good.
At this inspection we found that the provider had made some improvements however we found further improvements were required to become fully compliant with the Fundamental Standards of Quality and Safety. This is the second time the service has been rated requires improvement.
We found concerns with the safe administration of medicines, fire drills did not support staff to keep people safe and the personal emergency evacuation plans (PEEPs) were not in place for two people and were in place for one person who had left the service. The purpose of a PEEP is to provide staff and emergency workers with the necessary information to evacuate people who cannot safely get themselves out of a building unaided during an emergency. Following the inspection the fire service completed an inspection of the service and provided an urgent action plan for the provider to follow.
Audits were taking place; however, they were not robust enough to highlight the issues we found during our visit. Records, were difficult to locate and once found in no order. It was highlighted at the last inspection that the provider did not complete any quality assurance checks at the service and the registered manager did not record their daily walk around. We asked to see them at this inspection and we were told there were no records kept of daily walk arounds and the provider does not complete any records to evidence checks of the service.
Risks assessments arising from people’s health and support needs needed to include more information to minimise the risk, be more person centred and to be updated or new risk assessment put in place when people’s needs changed.
Risks arising from the premises were not always assessed. Doors leading to stairwells were not locked on opening but were locked on closing. Meaning if a person opened the door on the bottom floor they could climb upstairs but be greeted by a locked door and have to go back down, a person opening the door on the top floor would not be able to get back in once the door shut and would have to navigate the stairs.
People who lived at the service were safeguarded from abuse. People told us that they felt safe at the service and that they trusted staff. Staff were booked in for refresher training in the safeguarding of vulnerable adults and said they would not hesitate to report concerns.
The registered manager understood their responsibilities in relation to the Deprivation of Liberty Safeguards (DoLS). People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; policies and systems in the service supported this practice. Records relating to who had DoLS in place were not updated in a timely manner, therefore staff were not fully aware of who had a DoLS in place. We did not see evidence of consent being recorded in all the files we looked at or evidence to show consent had been provided verbally.
Some areas of the service needed a deep clean and updating. The provider had a refurbishment plan stating all works would be completed by December 2019.
Accidents and incidents were recorded and monitored for trends and patterns.
Staff training was up to date. Supervisions were up to date and appraisals were in the process of taking place and booked in.
We found there was sufficient staff employed to support people with their assessed needs on the day of the inspection. However, an extra member of staff had been brought in and the activity coordinator was being used to support care staff, taking them away from their own role.
Appropriate recruitment checks were carried out before staff were employed to ensure they were suitable to work with vulnerable adults.
Feedback on the quality of the service had been sought.
People enjoyed the food provided.
People were supported to continue with their preferred religious needs.
Staff demonstrated a person-centred approach to care and they knew people well. Care plans had very limited information of people’s wishes, preferences and life histories, but staff we spoke with had a good knowledge of this
We saw evidence of activities taking place and people we spoke with enjoyed them.
The service had a complaints policy that was applied when issues arose. People and their relatives knew how to raise any issues they had. The service had received four complaints since the last inspection.
We identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the registered provider to take at the back of the full version of the report.
Following the inspection the provider assured CQC that they have arranged for urgent works to be completed immediately. They had followed the fire services action plan and arranged a full independent review of the service.
This service has received a rating of 'Inadequate' in one or more domains and the service is therefore in 'special measures'. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration. For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.