Archived: Howdon Care Centre

Howdon Care Centre is a care home providing personal and nursing care for up to 90 people across four units, including a winter pressures assessment unit. The winter pressures unit is for people waiting for a care package at home or admission to a long term care facility. At the time of inspection there were 77 people living at the home, some of whom were living with dementia.

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

Medicines were not managed safely. Quantities of remaining medicines did not always match the records of doses administered, so we could not be assured medicines were administered as prescribed. Guidance and records were not always in place to support the safe administration of topical medicines. A recent provider audit had picked up some of the issues we found on inspection, but an action plan was not yet in place.

Whilst a system was in place to monitor and manage risks; improvements made at previous inspections had not always been sustained. The regional manager explained the new management team at the home and systems in place, would ensure a proactive, rather than reactive approach was followed in relation to the management of risk.

Lessons learned had been identified following several incidents at the home. Action was being taken to help reduce the likelihood of any reoccurrence of these incidents. New protocols had been introduced and additional falls equipment purchased. Further coaching sessions and training were being carried out in relation to falls management since records did not always demonstrate that the provider’s policy had been followed.

The provider had a history of non-compliance at the home. There had been a number of management changes at the home over recent years. There was a registered manager in post. She was the regional manager and employed in an interim position until a permanent registered manager was in post. There was a new manager in place at our second visit to the home.

An effective communication system to ensure information relating to people’s care and support was passed to staff in a timely manner was not fully in place. Some staff explained the quality of handover information was dependant upon the nurse on duty.

Records did not fully demonstrate how the provider was meeting their responsibilities under the duty of candour. We have made a recommendation about this.

At the time of the inspection, there were sufficient staff deployed to meet people’s needs. The home was clean and staff had access to and used PPE safely. There were no restrictions around visiting arrangements.

People spoke positively about the caring nature of staff. One person told us, "The staff are all lovely - I'm happy." Staff also spoke positively about the people they supported. One staff member told us, “I love it here, we’re a good team, it's not about the money - I love looking after them.”

Management staff were honest and open with us during the inspection. They themselves exhibited caring values and spoke positively about the changes which were being made to sustain improvements at the service.

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 good (published 24 May 2022). We carried out a targeted inspection in November 2022 to check concerns relating to IPC and the management of the service. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

We made a recommendation in the well-led key question in relation to sustaining improvements and the management and support of the home. At this inspection, not enough action had been taken and the provider was in breach of the regulations.

Why we inspected

The inspection was prompted by concerns about people’s care and support, the management of falls and medicines management. A decision was made for us to inspect and examine those risks.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Howdon Care Centre on our website at www.cqc.org.uk.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

Enforcement and Recommendations

We have identified breaches in relation to medicines management and good governance at this inspection. Please see the action we have told the provider to take at the end of this report.

We have made a recommendation in the well-led key question in relation to duty of candour. Please see this section for further details.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Howdon Care Centre is a care home providing personal and nursing care for up to 90 people across four units, including a winter pressures assessment unit. The winter pressures unit is for people waiting for a care package at home or admission to a long term care facility. At the time of inspection there were 75 people living at the home, some of whom were living with dementia.

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

We carried out this inspection because we received concerns about infection prevent and control (IPC). When we visited; we found action had been taken to improve. The home was clean and staff followed government guidance in relation to the safe use of PPE.

A quality monitoring system was in place. However, this was not always effective at ensuring improvements made were sustained. Whilst we acknowledged steps to improve had been taken when we inspected; the home had a history of non-compliance with the regulations including those relating to IPC. We sought further reassurance from the provider that these improvements would be maintained.

There had been a number of management changes at the home over recent years. There was registered manager in post. She was the regional manager and employed in an interim position until a permanent registered manager was in post. The registered manager had been supporting another of the provider’s care homes and had not been at Howdon Care Centre during the time period leading up to the inspection. She returned to the home immediately prior to the inspection. There was a new manager in place on the day of our visit to the home; however, they chose to resign before the end of our inspection. We have made a recommendation that the provider reviews the management and support of the home.

We wrote to the nominated individual following our visit to request how they were going to sustain the improvements made at the home. They sent us a detailed response about the action they were taking with regards to the management and support of the home.

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

Rating at last inspection

The last rating for this service was good (published 24 May 2022).

Why we inspected

We undertook this targeted inspection due to concerns received about infection control. A decision was made for us to inspect and examine those risks.

We use targeted inspections to follow up on Warning Notices or to check concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

We found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe and well led key questions of this full report.

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

Recommendations

We have made a recommendation in the well-led key question in relation to sustaining improvements and the management and support of the home. Please see this section for further details.

Follow up

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

Howdon Care Centre is a care home providing personal and nursing care for up to 90 people across four separate units. One unit specialised in rehabilitation and intermediate care. At the time of inspection 53 people were living in the home.

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

Risks were now being assessed, monitored and managed. Lessons had been learned since our last inspection and improvements had been made. Accidents and incidents were recorded, monitored and analysed to reduce the risk of reoccurrence. The home and equipment were clean. Staff used PPE effectively and safely.

There were sufficient staff deployed to meet people’s needs. Staff carried out their duties in a calm unhurried manner. Staff had time to speak with people and spend time with them which helped promote their wellbeing.

The provider had a safeguarding system in place. Staff raised no concerns about staff practices in the home. Staff were suitably trained. Safe moving and handling and infection control procedures were followed. We also observed positive interactions between staff and people who had a dementia related condition.

The quality and safety of the service was now being effectively monitored. Checks were carried out and action taken if any shortfalls were identified. Staff spoke positively about the registered manager and the improvements that had been made since they had been appointed. Some staff however expressed concern, because the registered manager’s position was only temporary until a permanent manager was recruited. Management staff were aware of the staff concerns and assured us that time was being taken to ensure the correct manager was appointed for the home.

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

Rating at last inspection

The last rating for this service was requires improvement (published 14 December 2021).

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 19 August 2021. Five breaches of legal requirements were found in relation to Safe care and treatment, Staffing (training), Person-centred care, Dignity and respect and Good governance. We took enforcement action and imposed conditions relating to infection, prevention and control upon the provider's registration. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

We undertook this inspection to check they had met the imposed conditions relating to infection control, followed their action plan and to confirm they now met legal requirements.

The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

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.

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

Follow up

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

Howdon Care Centre is a care home providing personal and nursing care for up to 90 people across four separate units. One unit specialised in rehabilitation and intermediate care. At the time of inspection 61 people were using the service.

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

People did not always receive person-centred care and risks to their health, safety and wellbeing were not always well managed.

Staff did not always follow government guidance relating to safe working practices regarding infection control, including the safe use of PPE. Inappropriate moving and handling techniques were used at times and accidents and incidents were not always appropriately recorded and analysed. There were not enough staff on duty on the first day of our inspection. The provider increased staffing levels on our second visit to the home which met people’s needs. We have made a recommendation that the provider keeps staffing levels under review to ensure sufficient staff are deployed to meet people’s needs.

Staff were not always suitably trained and skilled. An effective system was not fully in place to ensure best practice guidance was followed when providing care. The home décor did not fully meet people’s needs. Some areas of paintwork and flooring were damaged. In addition, the décor did not fully support the orientation and needs of those people who were living with dementia.

People did not always receive a high quality, compassionate and caring service. Some staff were more confident and skilled than others when communicating and interacting with people who were living with a dementia type illness. Staff practices did not always promote people’s independence or privacy.

Staff did not always meet people’s social needs. Some people were walking around without purpose and other people spent a lot of time asleep in their rooms. Staff did not always follow care plans when providing support and some care was task orientated.

An effective system was not fully in place to monitor the quality and safety of the service. Staff morale was low following a period of change. An interim manager had started at the service from another of the provider’s care homes, to support staff and manage the home.

Medicines were generally managed safely, although improvements were required in the recording of topical creams and ointments. We have made a recommendation about this.

Staff supported people with their nutritional needs and to access a range of health care professionals. People were supported to have maximum choice and control of their lives, and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice.

People and their relatives were involved in planning their care and their preferences were recorded. Complaints were investigated and actioned. People and relatives knew how to raise any concerns and felt confident in doing so.

Following our inspection, the provider told us action had been taken and improvements were being made.

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

Rating at last inspection

The last rating for this service was good (published 23 October 2018).

Why we inspected

We received concerns about the safety of the service from the local authority. As a result, we initially undertook a focused inspection to review the key questions of safe, effective and well-led only.

When we inspected we found there were concerns with the care people received, so we widened the scope of the inspection to review all of the key questions of safe, effective, caring, responsive and well-led.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

We have found evidence the provider needs to make improvement. Please see the safe, effective, caring, responsive and well-led sections of this full report.

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.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to Safe care and treatment, Staffing (training), Person-centred care, Dignity and respect and Good governance.

During the inspection process we imposed conditions on the provider's registration to ensure that they complied with government guidance in relation to safe infection control practices. for PPE, monitor and mitigate risk, and that the provider has systems in place to have oversight of risk and infection prevention and control. The provider told us that action had been taken and measures put in place to improve infection control practices within the service.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Howdon Care Centre is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. At the time of our inspection 59 people living with physical and mental health related conditions were using the service.

At the last inspection we identified five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, related to safe care and treatment, consent, complaints, staffing and good governance and one breach of the Care Quality Commission (Registration) Regulations 2009 in relation to unreported incidents of suspected neglect. We rated the service inadequate. Following the last inspection, we met with the provider to confirm what they would do and by when to improve the key questions safe, effective, caring, responsive and well-led to at least good. We asked them to complete an action plan and submit weekly updates, which they did. We imposed a condition on the provider’s registration to restrict them from admitting any new people into the home until we were satisfied the service was safe. At this inspection, we found improvements had been made at the service which ensured compliance with the fundamental standards.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures. We have also removed the restrictive condition on the provider’s registration.

A new registered manager was in post since our last inspection. A registered manager is a person who has registered with CQC 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.

At the last inspection we issued the provider with a warning notice for their failure to ensure good governance of the service. The provider indicated in their action plan that the registered manager and staff at the home were now effectively completing daily, weekly and monthly checks on the quality and safety of the service. They told us there was robust oversight by a regional manager, the managing director and the chief operating officer. We found that these checks had consistently taken place since May 2018. The registered manager had identified issues and resolved them promptly. We considered the provider now had thorough oversight of the service.

Record keeping throughout the service had significantly improved. The provider now held a clear and accurate record of the care and treatment people received.

After the last inspection we issued the provider with a fixed penalty notice because they had failed to ensure that all serious incidents were reported to CQC as legally required. We saw this had now been addressed.

Accidents and incidents were recorded on a central system and information about an investigation and an outcome was available to us. The registered manager ensured all incidents were reported where appropriate to the necessary authorities. This improvement meant that the registered manager and provider could carry out proper audits to analyse the information and look for trends which in turn would reduce a repeat occurrence within the service and across the organisation.

People told us they felt safe living at Howdon Care Centre. Family members we spoke with confirmed this. Staff were trained in how to safeguard vulnerable adults and through discussion they demonstrated to us that they were aware of their responsibilities with regards to protecting people from harm. Policies and procedures were in place to support staff with the safe and effective delivery of the service.

Medicines were managed safely. Apart from some minor issues which the clinical lead rectified immediately, we found no problems with the receipt, storage, administration, disposal or recording of people’s medicine.

The home was clean and tidy. Domestic staff were on duty and we observed them using best practice in terms of prevention and controlling the spread of infection. The home was nicely decorated and there were plans to replace the flooring. We identified a small number of minor repairs which the maintenance person attended to straight away. The premises were safe and regular checks were completed by internal and external personnel.

Staff continued to be safely recruited and from reviewing people’s dependency needs and the staffing levels we considered that there were enough staff employed at the service. The provider had used their disciplinary policy effectively to address the shortfalls in staff conduct following our last inspection.

Staff were now fully supported in their roles. The provider had assured themselves that staff were competent to provide safe care. New and existing staff had been enrolled onto a robust induction programme where necessary. Staff training was up to date. All staff had attended formal one to one supervision sessions and annual appraisals were being carried out and were scheduled in advance.

CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS), and to report on what we find. Applications had been made on behalf of some people to restrict their freedom for their own safety in line with the MCA. DoLS authorisations had been properly obtained and were monitored to ensure timely renewals took place.

The staff had ensured people or their family members/friends (where appropriate) had consented to the care and treatment they received. We saw that when people lacked the mental capacity to make their own decisions, a best interests meeting was held. The public Facebook page which had not been correctly monitored was suspended until the right consent was obtained and procedures for monitoring it could be properly implemented.

Information about people which was displayed outside of their bedrooms had been re-written. The staff ensured there were no sensitive details included and that the information was relevant to staff and people in terms of getting to know each other better. Consent to have this information displayed was obtained.

People were supported with their nutrition and hydration needs. A hot meal was served at mealtimes and people chose what they would like to eat. Alternatives were available. The kitchen staff were aware of people’s dietary needs and staff monitored people’s intake as necessary.

Staff treated people with dignity and respect. We saw staff were kind and caring towards people. People and family members spoke highly of the staff and said they were nice and friendly towards them. People enjoyed a positive relationship with staff and it was apparent that they knew each other well.

People received care and treatment which was person-centred. Risk assessments accurately described people’s current needs and the specific risks they faced. Care plans gave staff comprehensive information about how people would like to be cared for. We found these documents were consistently and meaningfully evaluated and reviewed.

Complaints were well managed. We saw complaints had been properly managed through the providers complaints process. Complainants had received a full explanation and a timely response.

There continued to be plenty of meaningful and stimulating activities for people to participate in. However, some people were not aware of what was available to them.

This unannounced comprehensive inspection took place on 17, 18 and 19 April 2018. This meant that the provider, staff nor people who used the service knew we would be arriving. At the last focussed inspection in November 2017, we identified four breaches of regulations which related to safety, people’s nutritional needs, staffing and the governance of the service. We asked the provider to take action to make improvements. We found whilst improvements had been made to the care of people with nutritional needs, insufficient improvements had been made to the service to ensure compliance with all of the health and social care regulations.

This is the second consecutive time the service has required improvement. 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.

A new care manager was in post who managed the service on a daily basis. They had been employed at the service for approximately three months. The care manager was in the process of applying to become the 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. The regional manager had only been assigned to oversee Howdon Care Centre four weeks prior to this inspection.

We undertook an observation around the home to look at the issues which had been highlighted to the provider at our last inspection. Whilst we found some action had been taken; we found the checks on the service were still not robust enough to ensure compliance with all of the regulations. Issues remained at the home which had either not been wholly addressed or had not been properly monitored to ensure that staff had complied with the tasks delegated to them.

The provider indicated in an action plan that the care management team deployed to Howdon Care Centre carried out daily, weekly and monthly checks of the quality and safety of the service and together with the care manager they were confident that issues had been addressed. We did not find adequate evidence to corroborate these checks had consistently taken place or were completed robustly enough to identify the continued issues we highlighted during this inspection.

Record keeping was poor throughout the service. The lack of accurate and thorough details recorded within documents meant that neither we nor the provider were able to ascertain if issues had been correctly identified and followed up properly with the necessary action. We found multiple incidents had not been fully investigated, escalated internally or reported to the relevant external authorities as required.

Accidents and incidents, some of which were of a safeguarding nature had been identified by staff and recorded on a central system, however they had not been identified by the care manager as reportable events and therefore people had been placed at risk because proper safeguarding procedures were not followed. More serious incidents which are required by law to be notified to CQC had also went unreported. Furthermore, due to poor record keeping and auditing, accidents and incidents were not properly monitored to look for trends or reduce the risk of similar occurrences.

Risk assessments were not always in place or did not accurately describe people’s current needs. We also found some care plans were out of date and did not reflect the care or treatment people required. This meant people were at risk of harm through not receiving the appropriate care and support.

Medicines were not always managed safely. Although there was little impact on people receiving their medicines correctly, we found multiple issues with record keeping which placed people at risk of not receiving the right medicines at the right time. We found some people’s medicines had been out of stock for up to two weeks before a resolution was sought.

Staff training was overdue for some staff and refresher courses in key topics had not been routinely carried out. Staff who should have completed a robust induction programme, known as the ‘Care Certificate’ had not achieved this. This demonstrated that the provider had not assured themselves that people were supported by staff who had the skills and competence to provide safe care. In addition, 25 staff supervisions were overdue and annual appraisals had not been conducted recently. This meant that staff had not been formally supported in their role or given a recognised opportunity to talk about their issues and any plans for development.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS), and to report on what we find. Applications had been made on behalf of some people to restrict their freedom for safety reasons in line with the Mental Capacity Act 2005. However, we found the authorisations had not been properly monitored and some granted applications had expired and no new application had been made.

Consent was not always appropriately gathered from people or relatives (acting legally on their behalf) and it wasn’t always recorded in line with the principals of the MCA. This meant that people’s rights, particularly of privacy may have been infringed. For example, a public Facebook page had been set up which contained photographs of people taking part in activities without the appropriate consent.

We were concerned about the amount of personal information which was displayed in a profile outside of people’s bedrooms. The information was intended to help staff get to know people better. However, we considered that the decision to display this in a communal area was not carried out in people’s best interests and some people’s profiles contained confidential information which was not necessary.

People’s needs and plans of care were inconsistently reviewed and not always routinely updated to ensure they reflected people’s current needs and preferences. This meant that some vital information about changes to need and support may have been missed by staff. Whilst we found most care plans contained person-centred information, other care plans were much briefer and more task based, with less specific information to guide staff.

Complaints were not managed in line with the provider’s complaints policy. Although complaints had been recorded on the central system, they were not properly investigated and detailed investigation notes were not made. We found that the procedures were inconsistently followed meaning some complainants were not aware if their complaint was being addressed or if there was an outcome. We also found that complaints were not responded to in a timely manner.

The premises were maintained to a decent standard and we found the home to be clean and tidy. Domestic staff were on duty during our inspection and we saw they were designated responsibility for specific areas of the home.

Following the latest fire and legionella risk assessments, actions which had been identified had not all been completed in a timely manner. This was addressed during the inspection. We noted that emergency pull cords had been tucked out of the way in two units of the home, however risk assessments were not in place to describe the alternative measures.

Staff continued to be safely recruited and we considered that there were enough staff employed at the service, due to the home not being full. How dependant people were on support from the staff was monitored to ensure staffing levels remained appropriate. However people and relatives perceived the home to be short staffed due to the frequent use of agency workers.

Improvements had been made to the general care of people with high risk nutritional and hydration needs. However,

We carried out an unannounced comprehensive inspection of this service on 30 November and 1 December 2016 and found the provider was meeting the fundamental standards of relevant regulations. At that time we rated Howdon Care Centre as ‘Good’ overall and ‘Good’ in all five domains. After that inspection we received concerns in relation to staff ability to support people who had compromised gag reflexes. As a result we undertook this focused inspection to look into those concerns. This report only covers our findings in relation to this topic. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Howdon Care Centre on our website at www.cqc.org,uk

Howdon Care Centre is a ‘care home’. People in care homes receive accommodation, nursing and personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. Howdon Care Centre accommodates up to 90 people across four separate units, each of which have separate adapted facilities. Two of the units specialise in providing care to people living with dementia and one provides general nursing care. At the time of this inspection 88 people were in receipt of care from the service.

The home has not had a registered manager since September 2017. A registered manager is a person who has registered with CQC 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 provider had recruited a new manager at the end of September 2017.

Although they had been reviewing the service and making changes we saw little evidence of good governance or leadership. We found the manager was not able to discuss confirm to us the needs of people who used the service or accurately described the layout of the service.

We found that there were insufficient staff employed and deployed at the service to ensure people’s needs were met. The provider used a dependency tool but this did not take into account the size and layout of the service, which was in effect four 20+ place homes. Thus staff were working in teams of three to five care staff with senior staff covering two units. We found staff were unable to meet people’s needs.

We identified a number of concerns around the management of health and safety risks such as appropriately supporting people who required adapted diets and individuals who were at risk of falls. The provider had been alerted to these concerns during recent safeguarding investigations. In response to this they had had organised a full range of training and supervision around supporting people who have compromised gag reflex to eat.

However, on the first day of the visit we observed staff not adhering to care plans for instance, giving people food that had not been fork-mashed, when they required their food to be of this consistency. Following the first day of the inspection the provider ensured action was taken to rectify this and the cooks sent adapted meals to units, which were identified for each person who required these meals. Also we found there were insufficient tables and chairs on each unit to ensure all of the people could eat in dining rooms and no adapted plates and cutlery were being used, which led to people struggling to consume their meal. Albeit drink dispensers were located in each lounge, these either did not have any glasses or people could not independently reach them. Staff’s ability to spend time in the lounges was very limited so people were not offered drinks other than at set times. We found that staff needed to improve the accuracy of their recording when monitoring peoples' fluid intake.

We found from the review of records that some people displayed behaviours that challenged but staff had not received training to deal with their behaviours safely and the actions they needed to take were not detailed in the care records.

Copious care plans were in place and often these were inaccurate. A lack of assessment tool led to staff being unable to record people’s needs and highlight any changes. Care plans were undated, staff did not evaluate how successful or determine the accuracy of them. The regional manager and manager accepted this was a gap. They told us the provider was in the process of reviewing the documentation and considering how to improve the assessment of people’s needs.

Maintenance checks of the building and equipment were completed, but the quality assurance systems had not picked up on the issues we noted in relation to the upkeep of the building, cleanliness and adherence to infection control procedures. On the first day of inspection we pointed out various issues with the up keep of the home, such as door locks being broken and mattresses being ripped. The regional managers ensured these were addressed and continued to review the service to identify the improvements that were needed.

Although staff understood the requirements of the MCA and DoLS authorisations, we found that records associated with this were not always clear.

Accidents and incidents were monitored, but we found improvements were needed around how the information was analysed and used. Also staff needed to review how they stored medicines and ensure the guidance for administering ‘as required’ medicines was clear. We found that in general medicines were administered in line with prescriptions but found the information in care records was incorrect.

Effective recruitment and selection procedures were undertaken before staff began work to ensure people’s safety. Safeguarding and whistleblowing procedures were in place. However the provider needed to ensure staff received regular training and supervision.

Following the inspection we wrote to the provider and asked them to put measures in place to address these issues and to supply us with a detailed action plan outlining the steps they intended to take in response to our concerns.

We identified four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, which related to safe care and treatment, meeting people’s nutritional needs, staffing and having good governance systems in place. We also identified that the service had not informed us that they were accepting younger adults who had learning disability and people living with a physical disability. You can see what action we told the registered provider to take at the back of the full version of the report.

Howdon Care Centre is registered to provide accommodation with personal and nursing care for up to 90 people. At the time of the inspection there were 79 people using the service. The home was divided into four smaller units, some of which supported people living with dementia.

The home had a registered manager who had been registered since December 2014. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 and relatives told us they felt safe at the home. Staff had received training in relation to safeguarding vulnerable adults. Any safeguarding matters had been recorded and reported appropriately to the local authority safeguarding team.

Checks on the safety of the home were undertaken to ensure that fire equipment and other safety issues were monitored. People had personal emergency evacuation plans to allow staff to support them appropriately in the event of a fire. Risks regarding people’s care needs were also assessed and reviewed.

Suitable recruitment procedures and checks were in place to ensure staff had the right skills to support people at the home. People told us there were sufficient staff deployed at the home to support their needs. Accidents and incidents were recorded and monitored to help identify any trends or concerns. We found medicines were appropriately managed, recorded and stored safely. The home was maintained in a clean and tidy manner. At the previous inspection we had noted equipment to support people’s personal care was not always available. At this inspection we saw there was plenty of wipes and personal care equipment available.

Staff said they had the right skills and experience to look after people. They confirmed they had access to a range of training and updating. The registered manager showed us the staff training system which indicated a high level on completion for a range of courses. Staff told us, and records confirmed regular supervision took place and that annual appraisals were undertaken.

The registered manager confirmed applications had been made to the local authority safeguarding adults team to ensure appropriate authorisation and safeguards were in place for those people who met the threshold for DoLS, in line with the MCA. We saw copies of applications still in progress and confirmation letters where DoLS applications had been approved.

At the previous inspection staff did not always understand the concept of assessing people’s capacity to make decisions or acting in people’s best interests. At this inspection we found action had been taken and, where necessary, best interests decisions had been undertaken and recorded.

People’s health and wellbeing was monitored, with ready access to general practitioners, dentists, opticians and other health professionals. Visiting health professionals told us staff were proactive in supporting people’s health needs.

People told us that overall they were happy with the food at the home. We observed meal times and saw food was generally of a good standard, looked appetising and was hot. Kitchen staff demonstrated knowledge of people’s individual dietary requirements. Changes had been made to the units supporting people with dementia to better support their needs and minimise distress.

People and their relatives told us they were happy with the care provided. We observed staff treated people patiently and appropriately. Staff were able to demonstrate an understanding of people’s particular needs. We observed staff supported people in a caring manner and with dignity and respect.

Care plans reflected people’s individual needs and were reviewed to reflect changes in people’s care. A range of activities were offered, including exercise classes, craft groups and other events. The registered manager told us the home now had access to a minibus to help people get out into the community.

A complaints process was in place and information about raising concerns displayed around the home. The registered manager told us there had been five recent formal complaints and demonstrated how these had been thoroughly dealt with and addressed.

The registered manager undertook regular checks on people’s care and the environment of the home. The regional manager told us she also carried out regular audits. Staff felt the registered manager and unit manager were both approachable and supportive. There were regular meetings with staff and relatives of people who used the service, to allow them to comment on the running of the home. The provider’s electronic quality feedback tool indicated a high level of satisfaction from relatives and people using the service. Staff feedback indicated there was a good team spirit at the home. Records were up to date and appropriately stored.

We found medicines were handled safely, and people received them at the times they needed them.

The acting manager told us that they were in the process of fully auditing and updating all the care records for people who used the service. We found care records were up to date and the information they contained matched the care being delivered. Staff had a good knowledge of people's care plans and their individual needs. Staff told us and records confirmed that there had been one formal staff meeting since our last inspection. We saw that a range of items in relation to care and record keeping had been covered. There had been one meeting with relatives. One of the comments recorded as being made by a relative said, "were encouraged by the consistent leadership.'

We found that care plans were up to date and contained good detail. We were able to track people's care through the records. We found that food and fluid intake were recorded in detail. The acting manager told us that each person using the service was allocated a trained nurse, or senior care, and two care staff as key workers. Nursing staff and key workers were responsible for maintaining accurate records.

People we spoke with were complimentary about the care delivered. One relative told us, 'I feel I can relax because I know they look after him. It's the little things they do that make you feel they are really looking after him.' Another relative said, 'I cannot say anything wrong; she always has clean clothes and her bed is changed every day."

We did not discuss medication with people who use the service. We therefore looked at their medication records and medicines supplies in detail and talked with staff. Overall, we found that medicines were not managed safely some medicines were not given correctly and medicine administration records were not always fully completed and legible.

We found some audits and checks on the quality of the service had been undertaken and meetings involving relatives and service users had taken place. However, we found that checks made on people's care records to make sure they were up to date or accurate had not been fully completed.

We found that records were not always accurate or up to date and were difficult to follow and understand. Some daily records were written in the wrong area of the care records.

Most care plans were specific and contained detail about the care to be delivered. One person who used the service told us, 'It's generally ok in here. It's very pleasant. I am quite happy." Some assessment information that would be used to inform care plans was not readily available. We found one instance where someone had not had access to the correct wound dressing for a number of days.

People were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place for the recording and handling of medicines.

Consistent levels of staffing were maintained to deliver the care required.

The provider had not monitored the quality of the service people received or undertaken audits of the care provided. Meetings with people who used the service or their relatives had not been held regularly.

We examined the case records of six people and found in some cases that care delivery records maintained within people's rooms were incomplete.

We looked at the environment in which people were cared for and the equipment available to support them in their daily lives.

We saw the ground floor accommodation had been fully refurbished, was bright, appropriately furnished and decorated. Bedrooms had new furniture and their en suite facilities had been refitted. One person we spoke with told us, 'Oh yes, I like my room.'

Doors leading to the bathrooms and toilets had been painted a different colour to other rooms to help people identify these facilities. Lounges had new carpeting and in a small quiet room a library had been created for people who used the service.

We noted bathrooms contained modern easy access baths. Wet rooms with showers were clean with good access. One staff member told us, 'The residents love the baths, they are absolutely fabulous."

We looked at the care records of four people who used the service. Care plans had been reviewed and, where necessary, rewritten to reflect people's changing needs. Records for food and fluid intake and for positional changes were fully completed and up to date.

We looked at four people's care plans. In particular we looked at moving and handling issues. We saw evidence that needs were assessed and care was planned and delivered in line with their plans. We observed the use of lifting belts to assist people who had difficulty in standing and did not view any unsafe practice in relation to lifting.

At the time of our inspection the lower floor of Swan Lodge was undergoing major refurbishment. We found there were no assessments to minimise risk from this work for people living there. We concluded people were not fully protected against the risks of unsafe or unsuitable premises.

We confirmed there was a staff training record. Staff told us they received regular supervision and that they had annual appraisals. We concluded staff received appropriate professional development.

We found some records were not complete. We saw the daily progress reports did not always reflect the care plan or the current concerns about people. Because the records did not reflect what was written in care plans or what we were told this created a risk that people may not receive the correct care.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time.