Howe Dell Manor

Howe Dell Manor is a converted manor house in Hatfield, Hertfordshire that accommodates up to 19 people living with mental health conditions. At the time of this inspection there were 17 people living at the service.

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

There had been improvements since the last inspection. Care plans were now in place to minimise risks and governance systems were widely used more robustly. Some further detail was required in the care records, but this did not detract from the care people received. Overall, we found whilst risk management was more effective, there were still some areas of staff practice that needed to be embedded. The provider had plans in place to address these.

People told us they were happy with the care provided and felt safe living at the service. Risks to people health and welfare were identified and assessed. People’s support needs were met by sufficient numbers of staff who were recruited safely. Infection control was promoted, and medicines were managed well.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People told us staff had the necessary skills to support them. Staff said they felt supported by the management team, enjoyed the training provided and were supported to develop. The provider had recently reviewed their training. A revised and improved training plan was due to be delivered.

People were supported to eat and drink and were able to choose how they spent their time. The provider continually assessed the premises and had an ongoing refurbishment plan in place.

People had access to ample communal areas and extensive grounds which were in use on the day of our visit.

Staff worked with a vast number of health professionals to support people.

People said staff were caring, treated them as an individual and listened to their views and opinions. People’s end of life wishes and preferences were discussed, and staff were trained to support people if this need arose. Complaints were investigated promptly and people told us they could speak up.

The management team were well thought of among staff and people. The provider monitored the quality of care in the service and continued to develop their governance systems to embed this practise. There were meetings and frequent contact with people, relatives and staff to get their views. Feedback was collated and shared and used to improve the service.

Rating at last inspection

The last rating for the service was requires improvement published on 27 July 2019.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Howe Dell Manor is a converted manor house in Hatfield, Hertfordshire that accommodates up to 19 people living with mental health conditions. At the time of this inspection there were 16 people living at the service.

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

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People told us they felt safe in the home and staff supported them in a kind and caring way. Staff knew how to report their concerns and keep people safe from harm. Medicines were managed safely. Risk assessments were developed and actions to mitigate risks were identified, however more detail was required to ensure staff had guidance on how to consistently apply measures to mitigate risks.

Care plans were developed in an electronic format and they were detailed in what people`s needs were and what support was needed from staff to meet those needs. These needed further development to ensure they accurately reflected people`s current needs, the support they were getting and to detail people`s likes, dislikes and preferences.

People were offered choices and staff knew they had to ask for people`s consent to support them with any aspects of care. People told us staff were kind and caring and their dignity and privacy was protected. The provision of individually tailored social activities was an area the provider was still working on to ensure people were living an active life. There were enough staff to support people with their daily needs, including support for people to go out when they wanted.

Staff felt supported to understand and carry out their job roles effectively. Training commenced to ensure staff were up-skilled to the roles of champions in their areas of interest. The interim management team were working to develop the way staff met people`s dietary needs.

Governance systems had improved since the last inspection. The way the provider collected feedback from people, audits and other data to help assess the quality of the service provided was more effective and helped the provider identify where more improvements were needed.

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 last rating for this service was inadequate (published 13 March 2019).

The provider completed an action plan after the last inspection and sent us monthly updates 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.

This service has been in Special Measures since 13 March 2019. During this inspection the provider demonstrated that improvements had been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

Follow up

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

At the last comprehensive inspection in June 2017 we found three breaches of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We rated the service overall as requires improvement. The areas of improvement identified were in relation to providing a safe environment, supporting decision making and consent, and leadership and governance.

At this inspection we found that improvements had been made to help ensure a safe environment however; other improvements had not been made and there were additional areas that did not meet the standards. We found breaches of regulations in relation to providing safe care, mental capacity and decision making, involving people in their care, staff training and leadership and governance of the service.

Howe Dell Manor 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.

Howe Dell Manor is a converted manor house in Hatfield, Hertfordshire that accommodates up to 19 people living with mental health conditions. At the time of this inspection there were 18 people living at the service.

The service had a manager who was in the process of applying to be registered. 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.

Systems in place to protect people from harm were ineffective. Incidents had occurred at the service which were not recorded or reported appropriately to ensure the safety of people. Staff had received training on safeguarding procedures but not all staff were clear about identifying where people were at risk.

Risks to service users’ health and well-being were not appropriately identified, assessed and managed. Risks assessments in place did not offer robust guidance to staff on how individual risks to people could be minimised. Assessments had not consistently been updated or reviewed following changes in people’s care needs.

Staff had not received sufficient training to meet the individual needs of people. Staff had been supported with regular supervision and appraisals, however staff supervision did not seek to develop staff skills further.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible; the policies and systems in the service did not support this practice. The requirements of the Mental Capacity Act 2005 and associated Deprivation of Liberty Safeguards were not met.

People told us that they had a variety of food and were complimentary about the meals that were provided at the service. However, on the day of our inspection, special diets were not catered for by the agency chef on duty.

People did not consistently receive caring support. Many people described staff as caring but others had experienced negative encounters. Language used in care records did not always promote people’s dignity.

Care plans took account of individual needs but lacked detail with regards to people's preferences, choices and individuality. The plans were not reflective of people’s needs and did not always include clear instructions for staff on how best to support people.

Quality assurance processes were not robust, effective or used to improve the service being provided. Audits had failed to identify the concerns found during our inspection. The provider and manager had not acted upon previous inspection feedback with a view to evaluate and improve practice and ensure compliance with the regulations.

The manager was a visible presence in the service and staff felt supported. However; the manager demonstrated a lack of knowledge about the systems in place at the service and had no awareness of the concerns we found. Staff were not clear on the visions and values of the provider organisation.

Safe recruitment processes were in place and had been followed to ensure that staff were suitable for the role they had been appointed to prior to commencing work.

People received support from health and medical professionals when required. Medicines were managed safely.

People's privacy was promoted throughout their care and staff sought people’s consent before any care was provided.

Complaints were consistently managed, recorded and responded to.

The service was clean and tidy. Relevant infection control procedures were observed. Cleaning schedules and routines in place demonstrated the improved practices at the service in maintaining a safe, clean environment.

During this inspection we found multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

The overall rating for this service is ‘Inadequate’ 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.

We carried out an unannounced comprehensive inspection of this service on 29 January 2016 and rated it ‘Good’.

The service does not have a registered manager. A new manager has been appointed but is not yet registered. 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.

An appropriate level of cleanliness was not maintained throughout the service. We found that people’s bedrooms and a number of communal areas were unclean and the methods used by domestic staff when completing cleaning tasks were ineffective. The courtyard and communal gardens were poorly maintained.

People's needs had been assessed and care plans took account of their individual needs but lacked detail with regards to their preferences, choices and individuality. Individual risk assessments were in place however these lacked guidance for staff on how individual risks to people could be minimised. Care plans and risk assessments had been regularly reviewed by senior staff however it was not evident how people, and their relatives if appropriate, had been involved in the process and their views included in the planning of care.

A consistent number of staff on duty was maintained however people and staff raised concerns regarding the staffing level at the service. A formal staffing level assessment had not been completed by the manager and a recent change to the shift pattern worked by nursing members of staff was reported to have had a negative impact on the staff team.

People’s capacity to make and understand the implication of decisions about their care were not consistently assessed or documented within their care records. There was no evidence that, where people lacked capacity to make or understand decisions, those made on their behalf had been made in accordance with the Mental Capacity Act 2005 and associated Deprivation of Liberty Safeguards. However, people’s consent was gained before any care was provided.

People told us there had been a recent deterioration in the quality of the meals provided at the service. People were supported to make choices in relation to their food and drink however inconsistent menu choices were offered due to the absence of regular kitchen staff.

A limited range of activities were provided at the service however we observed staff engage people in social conversations outside of times where there was a high demand for their assistance.

There was a complaints procedure and policy in place. People knew who to raise concerns with however the complaints book for people to record their concerns in was not confidential.

Quality assurance processes were not robust and there was a lack of evidence of any recent audits to check the quality of the services provided. There was no evidence as to how the completed audits were used to drive improvements in the service. The arrangements for the management and storage of personal documents for people living at the service was not robust.

People told us they felt safe. Staff understood their responsibilities with regards to safeguarding people and they had received effective training. Referrals to the local authority safeguarding team had been made appropriately when concerns were raised.

Staff felt that they were trained and had the skills and knowledge to provide the care and support required by people. New members of staff received an induction.

Safe recruitment processes were in place and had been followed to ensure that staff were suitable for the role they had been appointed to prior to commencing work.

Medicines were managed safely. Monitoring tools and audits of medicine stocks were completed regularly by nursing members of staff.

People's health care needs were being met and they received support from health and medical professionals when required however information recorded in relation to these appointments required further detail.

Staff were kind and respectful. People's privacy and dignity was promoted throughout their care. People were provided with information regarding the services available.

During this inspection we found the service to be in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can see what action we told the provider to take at the back of the report.

The service has a registered manager. 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.

People were safe and there were systems in place to safeguard them from the possible risk of harm. However, risk assessments did not give clear guidance for staff on how to manage and minimise the risk. The provider had not followed fire safety advice to ensure that each person had an individual evacuation plan. Medicine administration records were not always completed fully to show that people’s medicines had been managed safely.

The service followed safe recruitment procedures and there were sufficient numbers of suitable staff to keep people safe and meet their needs.

People were supported by staff who were trained, skilled and knowledgeable on how to meet their individual needs. Staff received supervision and support, and were competent in their roles.

Staff were aware of how to support people who lacked the mental capacity to make decisions for themselves and had received training in Mental Capacity Act (2005) and the associated Deprivation of Liberty Safeguards. People’s nutritional needs were met and they were supported to have enough to eat and drink. They were also supported to access other health and social care services when required.

People were treated with respect and their privacy and dignity was promoted. People were involved in decisions about the care and support they received.

People had their care needs assessed, reviewed and delivered in a way that mattered to them. They were supported to pursue their social interests and hobbies and to participate in activities provided at the home. There was an effective complaints procedure in place.

There were systems in place to seek the views of people, their relatives and other stakeholders. Regular checks and audits relating to the quality of service delivery were carried out. There were effective systems in place to monitor the quality of the service.

During this inspection we found that the provider was meeting the standards we had inspected. People's needs were assessed and met appropriately. There was a policy and procedures in place to report any allegations of abuse. There was a system in place for the safe administration and management of medicines. People were cared for and supported by a team of trained and qualified staff. There was a system for assessing and monitoring the quality of service.

During our visit to Howe Dell Manor, on 26 March 2013, we observed that there was some building and maintenance work being carried out. The provider told us the annexe was being converted into flats. There was a strong odour that could be associated with damp in the ground floor corridor. We were told that this was because a new concrete floor was being laid in the kitchen. However, other parts of the home showed visible signs of dampness. The area of the home where the work was being carried out was very cold.

The operations manager told us there had been a number of issues at the home recently and these were being addressed. A new manager had been appointed and had been in post since January 2013. The management team were working through some of the issues that needed to be addressed in the immediate, medium and long term.

Two people who lived at Howe Dell Manor said they were happy but other people made negative comments about certain aspects of the home, including making reference to a particular member of staff who they found difficult to get on with.