Howlish Hall Residential Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last inspection we rated this key question good. At this inspection the rating has changed to inadequate: This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to:

Regulation 12, Safe care and treatment

Regulation 13, Safeguarding

Regulation 15, Premises and equipment

Regulation 18, Staffing

Regulation 19, Fit and proper persons employed

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns and did not always investigate and report safety events. Lessons were not consistently learnt to continually identify and embed good practice.

We found audits of accidents and incidents had been completed by the previous manager up to April 2025; however, no audits had been completed after this date. Additionally, no analysis of accidents and incidents had been carried out beyond April 2025. There was no process in place to effectively monitor accidents and incidents, identify any trends or required learning to reduce the risk of reoccurrence. Failure to operate effective governance systems or have effective oversight placed people at increased risk of harm. One member of staff told us, “Sharing of any learning could be better, we need more information on any changes as a result of an incident, we don’t have a book to record things in.”

The service did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Care plans reviewed did not consistently demonstrate that people’s needs had been assessed prior to starting with the service. People who use the service would need to have what is called a pre assessment completed. There were none of these details recorded on the service’s electronic ‘Log my Care’ system. When we asked senior staff how pre-assessment information was accessed, they initially did not understand the request and required further clarification. Upon checking the electronic system, they were unable to locate any records. Eventually, 2 paper copies of pre-admission assessments were found. This raised concerns about the availability and accessibility of key information. As a result, we could not be assured that important details about individuals’ care and support needs had been effectively shared or used to support continuity of care when people moved between services.

An effective safeguarding system was not in place. The provider did not share concerns quickly and appropriately.

Staff did not consistently identify safeguarding concerns and report them to the appropriate internal and external agencies. During the inspection, inspectors were approached by a staff member who disclosed concerns which posed a risk to people who used the service. The staff member stated they had not reported the concerns to management or followed the providers safeguarding policy. We shared the safeguarding concerns with senior management who confirmed they were aware of these concerns as they had witnessed them but had not raised a safeguarding alert for this situation despite people being at potential risk from abuse. Providers are expected to ensure that all staff are trained, confident, and supported to identify and report safeguarding concerns, including those involving senior staff or managers. The lack of action placed people at potential risk of harm and abuse.

A review of training records showed that not all staff had completed the required safeguarding training. This meant there was a risk that some staff may not have the necessary knowledge or skills to recognise, report, and respond appropriately to safeguarding concerns.

Robust systems were not in place to protect people who used the service from the risk of theft or financial abuse. We reviewed financial administration records. The systems in place did not provide clear, auditable records of monies received into the service or how these funds were spent. For example, there was not a clear and accurate audit trail of any spending involving people’s personal money. Failure to ensure accurate and accountable financial records meant there was a significant risk that people using the service could be exposed to theft or financial abuse. The system in place at the time of our inspection failed to adequately safeguard people’s financial interests and ensure there was robust accountability within the service for people’s money.

The service did not consistently understand and manage risks. The service did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks to people’s personal safety had not consistently been assessed and plans put in place to minimise these risks. For example, we observed one person who had bedrails in place and a risk assessment to support the safe use of bedrails had not been completed. We could not be assured risks had been fully considered or mitigated. This put the person at risk of harm.

We reviewed a person’s care plan for using the bath hoist to access the bath. There was no assessment in place to support staff to understand how to assist the person to use the bath hoist safely. This placed the person at risk of not being supported safely, increasing the risk of harm.

We reviewed care plans and found that risks to people’s personal safety in the event of an emergency had not been adequately assessed. Some individuals did not have a Personal Emergency Evacuation Plan (PEEP) in place. Additionally, there was no other information recorded in their care records to indicate what level of support they would require in an emergency situation. This lack of planning exposed people to risk in the event of an emergency. The provider did not have an appropriate internet system in place to support staff in accessing care plans and daily records. During the first day of inspection inspectors were unable to access and review care plans due to a lack of internet connectivity. Staff confirmed that this was a regular occurrence. This poses a risk to people’s safety, as staff may be unable to access up-to-date care plans containing essential information about the care and support individuals require.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The provider had not properly maintained the premises. We found that on the first floor, the flooring was held down with tape as it had started to lift. The floor had been identified for repair in April 2025 and again in May 2025 without being fixed. Even though the repairs had not been carried out, a further audit was completed in June 2025 but failed to record the issues with the flooring. Failure to properly maintain areas such as flooring and failure to take action without delay placed people at risk of harm.

During the inspection we noted that the side panelling on one of the baths on the ground floor was secured using tape. This temporary fix is inadequate and posed safety and hygiene risks to people who used the service.

During the inspection we observed that one fire door did not close properly. A staff member confirmed this door was not scheduled for replacement and informed us that it required adjustment but there was no record that this had been identified prior to our visit. Failure to properly maintain fire doors placed people at risk in the event of a fire.

A covered smoking area (shed) was available for people who used the service. It was located away from the home’s main entrance, in a wooded area accessed via a pathway. However, there was no lighting along the path, which may pose a safety risk, particularly during the winter months when it gets dark earlier. The manager informed us that the shed had been placed in this location to prevent people from smoking near the front entrance. However, the smoking area had not been cleaned for some time. The bins were full, and there were numerous cigarette ends scattered around the area, creating an unpleasant and unhygienic environment. Providers must ensure that all external areas used by residents are safe, well-maintained, and hygienic. The lack of lighting and cleanliness posed a risk to people’s dignity, safety, and comfort.

We observed the pathways close to the building were narrow and covered with moss, which could present a slip hazard to staff and people who use the service. One of the pathways was also a fire exit. This is a potential risk to the safety of people particularly those with limited mobility or poor balance.

During the first day of our inspection, we observed a cupboard in the dining room containing electrical components that was not locked and therefore accessible to all. This presented a potential safety hazard, particularly to people who may be vulnerable or lack the capacity to recognise the risk. Electrical panels or equipment should be secured and access restricted to authorised personnel only, in line with health and safety regulations. This was highlighted to a staff member, who was asked to secure the cupboard. During our next visit, 2 days later, we found this cupboard was still unlocked and accessible to all.

During the inspection we reviewed the kitchen cleaning records and facilities. While the cleaning records were up to date, there were areas in the kitchen that were visibly dirty and in need of redecoration. This meant that despite cleaning being recorded, the quality and effectiveness of cleaning was not sufficient. A lack of cleanliness in food preparation areas poses hygiene risks and is not compliant with expected food safety standards.

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 monitored staff training this was not effective. It was unclear which staff members were up to date with their training. Additionally, some staff reported feeling unsupported by management. One staff member said, “We are currently on our 4th manager, and this has been difficult and testing.”

The provider failed to ensure that safe recruitment checks were consistently carried out to confirm that staff employed were of good character. Records reviewed showed that Disclosure and Barring Service (DBS) checks were not always completed. DBS checks provide information, including details of convictions and cautions held on the Police National Computer, and are a vital part of making safer recruitment decisions.

We reviewed staff recruitment files which did not consistently include any records of interviews. As a result, there was no documented evidence that the provider had assessed whether staff had the necessary qualifications, skills, and experience required for their roles. Safe recruitment practices are essential to protect people using the service from potential harm.

We found there was no evidence that staff had received a comprehensive induction to support them in carrying out their role and responsibilities. During the inspection we spoke with 6 members of staff about their induction. 5 of them confirmed they had not received an induction when they joined the service.

People were not always supported by staff who had the knowledge, skills and training appropriate to their role. The training records evidenced that staff had not completed training relevant to the needs of the people they were supporting. For example: supporting people with mental health needs and alcohol dependency, staff had not received training in these areas. This lack of training meant staff may not have the necessary skills and knowledge to support people safely and appropriately. One staff member told us they had not received any training since starting in their role. Another staff member said they only started to receive training when the recent manager started.

We reviewed staff files and identified that staff did not receive formal support via supervision and appraisals. Records showed some staff had not received any formal supervision. Some staff members had no records of supervision or appraisals in their staff files. The lack of these structured oversight limits opportunities for staff to develop, reflect on their practice, raise concerns, or receive guidance

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

During the inspection we observed the home to be unclean in various places throughout the premises. Paintwork was chipped throughout the home making it difficult to clean effectively to reduce the risk of infection. This included doors, door frames, handrails and skirting boards.

We observed there were certain areas of the home that the inspection team identified as not being cleaned daily during our inspection visits. For example, communal staircases were noted to have debris on them at the start of the inspection. It was still there the following day.

We reviewed the cleaning schedules and sign-off sheets. It was noted that the folder was poorly organised and contained a variety of different sheets without a clear structure. As a result, there was no clear audit trail to verify what cleaning tasks had been completed, or whether they had been carried out at all. Additionally, there was no documented guidance regarding the required frequency of carpet or curtain cleaning. Management oversight in this area was inconsistent. The sign-off sections of these records were required to be completed by the manager. These were not regularly completed.

Physical checks and observations of equipment showed us that items such as toilet frames and raised toilet seats in bathrooms on the ground and first floors were not cleaned. Door frames and skirting boards throughout the building were observed as being dirty.

Waste storage, segregation and handling appropriate measures guidance states that you must store and handle bagged waste on site in fully enclosed, lockable, rigid, leak-proof and weatherproof bulk containers. We saw the yellow clinical waste bin was unlocked. The waste bin area was situated at the rear of the building which was an area that could be accessed by the people who use the service and visitors.

Regular Legionella risk assessments are essential to identify and control potential sources of Legionella bacteria in water systems, ensuring the safety and health of residents and staff. Failure to carry out assessments increases the risk of Legionnaires’ disease and breaches health and safety Regulations. Providers must ensure that Legionella risk assessments are conducted in accordance with current legislation and guidance. We spoke with a staff member regarding safety checks for the service and requested the Legionella risk assessment. This was not provided. We spoke with the manager who confirmed they could not find a legionella risk assessment.

The provider did not always make sure that medicines and treatments were safe and met people’s needs.

We could not be assured that people were receiving their medicines as prescribed. A medicines management audit completed in July 2025 identified discrepancies in medication balances for several individuals. However, the audit did not explore the causes of these discrepancies, nor did it include any recorded actions to address the errors or prevent recurrence. This lack of follow-up placed people at continued risk of harm due to potential medication errors.

Medicines must be stored within specific temperature ranges to maintain their safety and effectiveness. However, during our inspection, we found the medicine storage room to be extremely warm upon entry. Temperature records showed that readings were typically taken in the early morning and were mostly recorded at or below 25°C. A senior member of staff confirmed that by mid-afternoon, the room temperature often exceeded 25°C. This practice placed medicines at risk of being compromised due to inappropriate storage conditions.

Medicine administration records were not consistently completed when individuals refused their medicines or were away from the service on home visits. As a result, it was unclear whether people had received their medicines as prescribed, and if not, the reasons for this were not always documented. This lack of recording compromises the safe management of medicines and continuity of care.