Archived: Homecrest Care Centre

Homecrest Care Centre provides accommodation for up to 29 people who need help with personal care. At the time of the inspection 24 people lived in the home. Most of the people living in the home lived with dementia.

People's experience of using this service

At this inspection, we identified serious concerns with the management of risk, care planning and delivery, the management of medicines, staff recruitment, staffing levels and service management.

People’s needs and risks were not always properly assessed or managed. Guidance on the support people needed to keep them safe and well was not always in place for staff to follow. This placed people at risk of inappropriate or unsafe care. People’s health needs and checks had not always been followed up with other health and social care professionals to ensure their health remained stable.

People were not always protected from the risk of abuse. Some people had experienced unexplained bruising that had not been investigated and reported appropriately to protect them from harm.

Medication management was not always stored or managed safely. Staff lacked sufficient guidance on how to administer as and when required medicines; diabetes management and medication allergies. It was difficult to tell if some medicines were administered in accordance with the manufacturer’s instructions. The competency of some staff to administer medicines had not been assessed to ensure sure they were safe to administer medicines.

There were not enough staff on duty to meet people’s needs at all times. Staff and the people we spoke with confirmed this. Staff were kind and caring but were task orientated. People told us staff did their best but there wasn’t enough of them.

Fire safety arrangements were not adequate; staffing levels at night were a serious concern as they were not sufficient to ensure all people could be evacuated in the event of a fire. The fire evacuation procedure was unclear and there was not enough evacuation equipment in place to help people evacuate.

There was not enough domestic cover to ensure the home was thoroughly clean to good infection control standards. The arrangements in place to mitigate the risk of COVID-19 were also not robust.

Staff recruitment was not safe. The necessary checks on staff suitability had not always been checked fully prior to appointment to ensure they were safe to work with vulnerable people.

The management and leadership of the service was poor. Neither the manager or, the provider had identified the issues we found at the inspection. This was despite a range of audit systems being in place to monitor the quality and safety of the service.

The manager did not demonstrate they understood the service, people’s care needs or their regulatory responsibilities.

Rating at last inspection

The last rating for this service was requires improvement (published 08 February 2020).

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

At this inspection, we found that the quality and safety of the service had significantly declined. Multiple breaches of the regulations were found, resulting in a rating of inadequate.

At this inspection, breaches of regulations 12 (safe care and treatment); 13 (Safeguarding people from the risk of abuse); 17 (Good governance); 18 (Staffing) and regulation 19 (Fit and proper persons) of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, were found.

Why we inspected

We conducted a focused inspection in response to information of concern shared with us by the Local Authority and the general public about the service. As a result, we undertook a focused inspection to review the key questions of safe, and well-led only.

We reviewed the information we held about the service. No areas of concern were identified within the other domains of ‘effective’, ‘responsive’ and ‘caring’. We therefore did not inspect these domains. Ratings from previous comprehensive inspections for these key questions were used in calculating the overall rating at this inspection.

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

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

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.

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

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

Follow up

We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner. We will work with the local authority to monitor progress.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service had been placed in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.

Homecrest Care Centre provides accommodation with nursing or personal care for up to 29 people. There were 10 people living in the home when we visited.

People’s experience of using this service:

Since 2016, the provider has failed to comply in full with the Health and Social Care Act. At this inspection however, we found that the provider had improved the service and were no longer in breach of the regulations.

Some areas of the service still required improvement. Staff needed clearer guidance and systems in place to ensure that ‘as and when’ required medication were administered in a timely manner. Some people’s mobility and moving and handling information was still confusing which placed them at risk of inappropriate or unsafe support. We spoke with the manager about this and they told us they would address these outstanding issues without delay.

The management of medication within the home was now safe. Improvements had been made to how people’s medicines were ordered, stored, administered and audited. Records showed people received the medicines they needed and documentation in relation to this was properly maintained. This meant that medicines were now managed in accordance with best practice guidelines published by the National Institute of Social Care (NICE)

People’s care plans contained information about the person’s needs and risks and were easy for staff to understand and follow. Record keeping in relation to people’s day to day care had significantly improved and showed that people received the support they needed to maintain their health and well-being.

People’s care was person centred and staff were kind, caring and compassionate. People looked smartly dressed and content. There were activities for them to join in with, including regular trips out and visits from school children from a local school, which we were told everybody really enjoyed.

The home’s environment was bright and airy and ongoing improvements had been made to the garden with new paving stones and a herb garden for people to enjoy. The home’s equipment and utilities were regularly checked and safe to use.

Relatives we spoke with told us that over the last 12 to 18 months, the home had really improved. They told us the manager was open and approachable and that they were always made to feel welcome when they visited. At this inspection, relatives told us they were more than happy with their loved ones’ care.

Staff members were recruited safety and completed sufficient training to do their job roles effectively. Staff told us they felt supported by the manager and that staff morale was good. Staff spoken with were knowledgeable about people’s needs and we saw that there were enough staff on duty to support people appropriately.

The systems in place to monitor the quality and safety of the service were now used to identify and drive up improvements to the service. This had resulted in significant improvements to the delivery and people’s experience of their care.

These improvements now need to be sustained to show that the leadership of the service is effective in ensuring people receive good high quality care at all times.

Rating at last inspection and update

At the last inspection the rating of the service was inadequate (Report published 19 July 2019). At this inspection, the service has been rated requires improvement.

Why we inspected

We inspected this service within six months of the last inspection as enforcement action had been on-going and we needed to be sure improvements were being made.

Enforcement and follow up

At the last inspection, enforcement action was taken to restrict admissions to the service until significant improvements were made. At this inspection, these improvements had been made. The provider now needs to evidence these improvements can be sustained.

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.

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

People’s experience of using this service:

Since 2016, the provider has failed to comply in full with the Health and Social Care Act. Continued breaches of regulations 12 and 17 with regards to safe care and treatment and good governance have been identified since 2016 and were found again at this inspection.

After the last inspection in February 2019, CQC took enforcement action to encourage the provider to drive up improvements at the service. This included restricting the provider’s ability to admit new people into the home without CQC’s approval until such improvements were made.

At this inspection, we found that although improvements were on-going, the provider has still failed to address the concerns we had about the service in any effective way. The issues identified at the February 2019 inspection and prior to that with regards to regulations 12 and 17 remained the same.

Some of the systems and processes in place to monitor the quality and safety of the service remained ineffective in identifying and driving up improvements. This meant that the service was not well led. The governance of this service has been a persistent and on-going concern.

At the last inspection, we raised significant and serious concerns about the management of medication. At this inspection, we found little action had been taken by the provider or manager to address them. Medication management failed to adhere to best practice guidelines published by the National Institute of Social Care (NICE) with regards to the storage, administration or management of medicines. This meant it continued to be unsafe and place people at risk of avoidable harm.

Despite the provider introducing a system to check people’s care planning information, people’s care plan still did not always contain sufficient or accurate information about their needs and risks or the care they required.

Information about the home was not always available in a format people could easily understand. For example, the complaints procedure was written in small typed print and there was no service user guide for people living at the home to refer to. This meant the service did not comply in full with the Accessible Information Standard introduced by the Government in 2016.

During our visit, we found that people’s privacy and right to dignity was not always maintained. This was because staff sometimes openly discussed people’s needs and care in communal areas where other people could hear these conversations. This was not good practice. We drew this to the manager’s attention.

There were however some good aspects of service delivery. For example, where people’s capacity to consent to their care was in question, the Mental Capacity Act 2005 (MCA) had been followed appropriately.

Records showed that when people became unwell or needed additional support they had access to a range of health and social care professionals in respect of their well-being.

Staff recruitment was safe. Appropriate checks were undertaken to ensure staff employed were suitable to work with vulnerable people. Staff had access to a mandatory training to do their job role and received regular supervision from their line manager.

The number of staff on duty was sufficient to meet people’s needs. People told us staff were always around to help them when needed. They said staff were friendly, kind and caring. They said they liked living at the home.

The atmosphere at the home was relaxed and homely. It was clear that staff and the people they supported had built up positive relationships with each other. The manager was a visible in and around the home and the people we spoke with told us they were approachable and friendly.

Rating at last inspection and update: At the last inspection the rating of the service was requires improvement (Report published 19 March 2019). At this inspection, the service has been rated inadequate. This is because the provider has consistently failed to ensure that regulations 12 and 17 were met.

Why we inspected: We inspected this service within six months of the last inspection as enforcement action had been on-going and we needed to be sure improvements were being made.

Enforcement and follow up: Due to the service having an overall rating of inadequate, the service will remain in special measures. Services in special measures are kept under review by CQC and are re-inspected within six months to ensure they continue to improve. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. As the provider has made some but not all the required improvements at this inspection CQC has considered its regulatory response and is taking action in line with our enforcement procedures and legal advice.

Enforcement action can involve the cancelling of the provider’s registration or to varying the terms of their registration. The action taken will be added to this inspection report after any representations or appeals from the provider have been concluded.

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

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

Homecrest Care Centre 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 home offers accommodation for people who require support with their personal care. There are 29 single bedrooms with a passenger lift enabling access to bedrooms on the upper floors. Four of these bedrooms are reserved for people who require emergency admission to the home or respite care.

On the day of our visit, there was a registered manager in post. 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. At the time of this inspection, the registered manager was absent from work and had been for some time. An interim manager was in post to manage the service in their absence. The interim manager commenced in post in September 2018.

At our last inspection in July 2018 we identified breaches of Regulations 9, 12, 13, and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches related to person centred care, the management of risk, the safeguarding of vulnerable adults and the governance arrangements in place at the home. After the July 2018 inspection, the home was placed in special measures. CQC served a notice to add a condition to the registration of the service with CQC. This condition meant that the home had to seek permission from CQC if they wanted to admit any new person to the home

At this inspection, we checked to see if the provider had acted on the concerns we had identified. At this inspection the standards of care at the home had improved significantly but the provider still had some improvements to make to achieve full compliance with the health and social care regulations. This was because there were continued breaches of regulations 12 and 17 identified again. At the last inspection, the service was rated overall inadequate. At this inspection as a result of the improvements made, the service has been rated ‘requires improvement’.

We found that the majority of people’s needs and risks in the delivery of care were assessed and had suitable management plans in place for staff to follow. Further action was required with regards to the support of one person’s health condition and two other people’s mobility needs. A recent trip out organised for two people who lived at the home had also not been properly risk assessed or managed. These issues meant that the provider had not sufficiently responded to the concerns we identified at the last inspection with regards to risk management.

At the last inspection the management of medication required improvement. At this inspection, the management of medicines had declined further. This placed people’s health and well-being at risk. We found that medicines were not properly accounted for. This meant it was difficult to tell what medicines had been received into the home and whether they had been administered correctly. We spoke with the interim manager about this. They agreed that urgent action needed to be taken to ensure medication management was safe. After the inspection, we referred our medication concerns to the local authority for investigation.

The system in place to identify and respond to potential incidents of abuse had improved to protect people from risk but notifications of potential abuse to CQC had not always been made.

The provider had still not ensured that the home’s electrical installation was certified as safe to use. We drew this to the provider’s attention again and it was subsequently organised. It should not have taken inspectors however to have to point this out again to the provider before action was taken.

The communal lounge, dining room and some people’s bedrooms had been redecorated. New flooring, armchairs and other furnishings had been purchased which made these areas bright and fresh looking. The home was cleaner and no longer smelt. A new boiler had been purchased to ensure there was sufficient hot water in the home and a sluice room for the washing and disinfecting of people’s personal items was in the process of being installed.

We saw that people got enough to eat and drink and at this inspection people’s opinions on the food provided was positive. At lunchtime we saw that some improvements to the way people’s meals were served had been made. For example, there were tablecloths and napkins on the table, people were given a choice of two meal time options and there was appropriate cutlery for people to use to maintain their independence. People who needed help to eat and drink received support to do so. Further improvements were required to ensure that people were not waiting a long time to be served their first course once they had sat down at the table for their meal.

During our visit we noted that people were smartly dressed and looked well cared for. Records showed that they had received regular access to a bath or shower, oral hygiene and other personal hygiene support. People’s care had improved to meet their individual needs. People also had access to a range of in-house activities to occupy and interest them in support of their emotional and social well-being. Activities or trips outside of the home were still not routinely organised despite people’s expressing a preference for this at the last inspection.

At this inspection, staffing levels had not changed from the previous inspection but there were fewer people living in the home. At the last inspection the service was chaotic and disorganised. At this inspection, staff had the time to support people in a person centred way. The atmosphere was much calmer and relaxed. This was a significant improvement.

Staff recruitment was safe and the interim manager had ensured all appropriate pre-employment checks had been undertaken prior to new staff commencing work at the home. Staff had received training and support to do their job. People we spoke with and their relative were all positive about the support provided. No-one we spoke with at the time of the inspection had any complaints.

The provider’s governance arrangements for the monitoring and management of the service had improved but were still not sufficiently effective in identifying quality and safety concerns.

The overall rating for this provider is 'Requires Improvement'. However the safe domain's rating has not changed and due to the concerns identified remains rated as inadequate. This means that the service will remain in 'Special measures'. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

The service will 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 we will move to close the service by adopting our proposal to vary the provider's registration to remove this location from the providers registration.

Homecrest Care Centre 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 home offers accommodation for people who require support with their personal care. There are 29 single bedrooms with a passenger lift enabling access to bedrooms on the upper floors. Four bedrooms are reserved for people who require emergency admission to the home or respite care.

On the day of our visit, there was a registered manager in post. 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.

At our last inspection in January 2018 we identified breaches of Regulations 10, 12, 17, 18 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches related to dignity and respect, the management of risk, the safe recruitment of staff, staff training and the governance arrangements in place to manage the home. After the January 2018 inspection, the provider submitted an action plan to CQC outlining the action they intended to take to improve the service.

At this inspection we found that the provider had not taken sufficient action to address all of the breaches we had previously identified in accordance with their action plan. We identified continued breaches of Regulation 12 (safe and appropriate care) and Regulation 17 (good governance), and additional breaches of Regulation 9 (person centred care) and Regulation 13 (safeguarding of people from the risk of abuse and improper treatment). The concerns we identified during this inspection were serious and significant and we were concerned about people’s immediate welfare.

We reviewed seven care records. Risks associated with people’s care were assessed and staff had guidance on how to manage these conditions. Records showed that staff did not always follow the risk management advice in order to protect people from harm. One person’s medical needs were not monitored in accordance with risk management guidelines and two people’s challenging behaviours were not always supported appropriately. At times this had resulted in staff and the person sustaining physical harm due to the use of unauthorised restraint techniques.

We identified that a number of serious safeguarding incidents had not been appropriately reported, investigated or responded to by the manager or provider in accordance with local safeguarding procedures or CQC requirements. This meant that the manager and provider failed to take appropriate action to protect and prevent the risk of people experiencing abuse or improper treatment.

Some people’s bedrooms smelt extremely offensive and it was difficult to comprehend that people still lived in these conditions. Some of the home’s communal areas were also malodorous and unpleasant to be in but despite this no action had been taken by the provider to improve people’s living conditions. The home’s boiler frequently tripped which meant that at times people did not have access to hot water to wash in. On day one of the inspection, there was no hot water in the home when we arrived. Records showed that the temperature at which the home’s water was stored was not sufficient enough to control the risk of Legionella bacteria developing in the water supply. This meant that risks to people’s physical health and well-being were not mitigated against.

People’s medication was stored securely but not always at safe temperatures. This meant there was a risk that some of the medicines were not safe to use. People’s medication administration records showed that some people had refused their medication or were not given it because they were sleepy but there was no evidence that they were re-offered it at a later time the same day. This meant the medication was missed. We found that people’s ‘as and when’ required medication was not given in a timely or effective manner in accordance with their ‘as and when’ required medication plans. This meant that people did not receive the medicines they needed to relieve discomfort or distress.

People got enough to eat and drink but people’s opinions on the food and drink provided were mixed. Two people told us the quality of the meals had declined. At lunchtime, people’s ability to choose and exercise control over what they ate and drank was not actively promoted and people’s meals were served in a disorganised and chaotic environment. It was not conducive to a pleasant dining room experience. Some people were observed to need assistance to access the right cutlery or to eat their meals but staff either did not notice or were too busy to provide the support people needed. Inspectors intervened on two occasions to ask staff to support people.

People’s opinions on the number of staff on duty were mixed. A staff member we spoke with felt the home was short staffed at times. When we checked the system the provider used to determine safe staffing levels, we found it was not robust. This was because the system in place failed to take account of people’s psychological and emotional needs. During our inspection we observed this was a much needed aspect of people’s care that was not adequately provided for. This did not show that the provider had considered all aspects of people’s needs and care in the management of the service.

At this inspection we found that standards of care at the home had declined and the quality and safety of people’s care placed them at risk of serious harm. This demonstrated the management of the service was inadequate both at provider and manager level.

We found that the provider’s governance arrangements had either failed to identify the concerns we found during the inspection or had identified them but little action had been taken to address them. The day to day management of the service was observed to be reactive and complacent with regards to improving the service and people’s quality of life. The lack of action and supportive involvement of the provider to make positive changes to the delivery of the service did not demonstrate that they were accountable or responsible for the care people received.

The overall rating for this provider is 'Inadequate'. This means that it has been placed into 'Special measures' by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

The service will 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 we will move to close the service by adopting our proposal to vary the provider's registration to remove this location from the provider's registration.

Homecrest Residential Home provides accommodation for up to 29 people who require support with their personal care. The home is located in a residential area of Wallasey, Wirral and has a small car park at the front of the home. There are 29 single bedrooms, most of which have en-suite facilities. The bedrooms are situated across three floors. The home’s upper floors are accessible via a passenger lift. On the days we inspected there were 26 people living at the home.

There was a registered manager in post at the time of our inspection. 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.’

Prior to this inspection in December 2017, a new nominated individual was appointed for the service. A nominated individual is responsible for supervising the management of the home.

At our last inspection in August 2016, we identified breaches of regulations 12 (safe and appropriate care), 16 (the handling of complaints) and 17 (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. After the August 2016 inspection, the provider submitted an action plan to The Commission outlining the action they would take to improve the service.

At this inspection, we found that although some improvements had been made to address the issues identified in the August 2016 inspection, the improvements undertaken were insufficient. This meant that the service continued to be in breach of regulations 12 and 17. We also identified additional breaches of regulations 10, 11, 18, 17 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This meant that service’s ratings for safe, caring and responsive were downgraded to inadequate for safe and requires improvement for caring and responsive. The overall rating for the service remained unchanged but means that the service has been rated requires improvement for the second time in a row.

During our visit we found that changes in people’s nutritional risks were not always responded to in a timely manner. Staff were recording people’s weights on a monthly basis but failed to identify and address a consistent pattern of weight loss for two people.

Parts of the premises were unsafe and on day one of the inspection parts of the home were also unclean. The window restrictors in place on people’s windows to prevent a fall were of poor quality. The radiator covers in place were not secure and some areas of the home smelt offensively. On day one of our visit, one of the fire exit doors was open but no alarm had sounded to alert staff and one of the home’s fire exits was partially obstructed with mobility equipment. These obstructions were removed by day two of our inspection.

The administration of medication was not always safe. The systems in place to account for the medicines in the home had improved but during our inspection we observed a member of staff sign a person’s medication chart without having observed the person take their medication. One person’s ‘as and when’ required medication plan for anxiety and distress was also not followed.

Staff recruitment procedures were unsafe. New staff employed in 2017 did not have adequate information collated by the manager in respect of their suitability to work in the home prior to their appointment. The information that had been collated had also not been verified. One staff member had been recruited without adequate information and had not received sufficient training to do their job role yet they were promoted to a more senior role within the home a month after their appointment. Concerns were subsequently raised with regard to this staff member’s conduct. These concerns were reported to CQC and the local authority but the provider failed to report their concerns to the Disclosure and Barring Service (DBS) so that they consider whether this person needed to be ‘barred’ from working with vulnerable adults or children.

People’s ability to make informed decisions had not always been assessed when their capacity to do so was in question. We saw that one person’s liberty was being deprived without the correct legal processes having been followed. Another person’s clothing had been removed from their bedroom without a capacity assessment and or any evidence that a best interest decision making process had taken place to ensure this was in the person’s best interests. This showed that people’s right to consent to their care was not always respected.

People did not always receive the support they needed at mealtimes to promote their dignity and to ensure their nutritional needs were met. Some people’s fingernails were dirty which did not demonstrate adequate personal hygiene support and people’s confidential personal information was displayed around the home which compromised their right to confidentiality. Some of the language used by staff was not always appropriate. They referred to the communal lounge as ‘high risk’ which may have given visitors a false impression of the people who sat in there.

Care plans contained person centred information about the person and their likes and dislikes. Communication and cognition plans also gave staff guidance on how to promote people’s ability to express themselves. This was good practice. We found however that some of the risk assessments and care plans in place lacked sufficient detail and some of the guidance given to staff when supporting people was contradictory.

People’s needs were reviewed monthly but the information in people’s reviews about their progress was limited. Care staff we spoke with had an understanding of people’s needs and the support they required. The majority of people we spoke with felt staff were kind and caring towards them and the relatives we spoke with spoke positively about staff.

Staff training records showed that long standing members of staff received adequate training to do their job role but new staff had not received adequate training before they worked with vulnerable people. All staff members had received regular supervision.

The number of staff on duty was sufficient to meet people’s needs but staff were mainly task orientated in their interactions with people. We saw that staff had little time to sit and chat to people in a meaningful way.

We found that the layout of the communal lounge impacted on the feel of the home. People were sat around the edges of the room which was not very conducive to social interaction and at various points throughout the day staff sat at the top of the room writing people’s notes. This gave the lounge a ‘classroom’ feel. People’s movements around the home were restricted and most people sat for the majority of the day in the communal lounge, without independent access to their bedrooms.

People told us they got enough to eat and drink and they were generally satisfied with the food and drinks on offer. The majority of people told us they were happy at the home and relatives said they felt their loved ones were safe and well looked after.

Care staff had a good knowledge of safeguarding and the action to take should abuse be suspected. Safeguarding incidents were properly investigated and documented by the manager.

People had access to activities each day and there was lots of evidence of people enjoying regular trips out for instance, to the cinema, bowling, local festivals, museum trips etc. On day one of our visit, a poetry reading took place and on day two of our visit people enjoyed a reminiscence session. Activities on both days lasted approximately two hours and for the remainder of the day people were observed to sit in the lounge.

Nobody we spoke with had any concerns or complaints about the service. The complaint records we looked at showed that complaints received had been responded to appropriately by the manager.

People views about the quality of the service were sought through an annual satisfaction questionnaire. We saw that the results of the latest survey were positive.

There were a range of regular audits in place to check the quality of the service. Some of the systems were ineffective as they had failed to identify the concerns we found during our inspection. For instance with regards to people’s nutritional support, staff recruitment, new staff training, premises issues, implementation of the Mental Capacity Act, medication administration and the promotion of people’s dignity and respect. This meant the way the service was governed required improvement to be effective in mitigating risks to people’s health, safety and welfare.

At the end of our inspection, we discussed the concerns we identified during the inspection with the manager, deputy manager and area manager. They were open and receptive to our feedback.

The home 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.’

During our visit, we found breaches of three regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulated Activities 2014. These breaches related to the provision of safe and appropriate care, medication management, complaints and the management of the home You can see what action we told the provider to take at the back of the full version of the report.

We reviewed three care records. We saw that care plans contained person centred information about the person and their life prior to coming to the home. Each care plan was holistic and reflected people’s needs and care. Risks associated with people’s care were assessed and staff had guidance on how to manage these conditions to prevent further decline. We found however that professional advice in relation to one person’s nutritional risks had not been appropriately followed up. This meant that staff could not be sure that the support provided was the safest way to manage the person’s nutritional risks. This placed the person at potential risk of harm.

Some of the moving and handling techniques used by staff in support of people’s mobility needs were inappropriate and placed people and staff at risk of accident and/or injury. We asked the manager to address this immediately.

The premises and equipment at the home had been regularly checked and inspected. Records showed persistent faults with the passenger lift and we saw that this had impacted on at least one occasion on the delivery of care. We spoke to the provider about this. They assured us that work was due to take place to resolve this. We found that some of areas of the home were unbearably hot. Elderly people are at increased risk of infection and dehydration in high temperatures. No appropriate action had been taken to ensure that temperatures were monitored and adjusted so that people were protected from any potential health risks arising from unsafe room temperatures.

Medication was given to people in an appropriate and pleasant way but the way in which medication was accounted for at the home was not satisfactory. This meant discrepancies in stock levels and administration errors were not always picked up.

People’s nutritional needs and risks were assessed and planned for. People were given a choice of suitably nutritious meals of sufficient quantity. People told us the food was satisfactory but that a bedtime drink was no longer routinely provided which meant that sometimes the last drink they received was at teatime. This meant there was a risk that some people would go long periods without a drink. We saw that one person required a pureed diet. The way in which this diet was prepared required improvement to ensure their dietary intake was supported in the best way possible. People who required assistance to eat at mealtimes where supported in a patient, sensitive manner by staff.

Where people had mental health issues, care plans contained person centred information to enable staff to understand the person and the impact these mental health issues had on their day to day life. We saw that there were the beginnings of good practice in relation to the implementation of the Mental Capacity Act. We saw that where people were deprived of their liberty, people’s capacity to keep themselves safe outside of the home was assessed prior to this decision being made. This was in accordance with legislation designed to protect people’s legal right to consent. We found however that capacity assessments lacked evidence of the person’s involvement in their own assessment and the decision making process. The implementation of the mental capacity act required further development in this area.

We noted some elements of good leadership in the service. People told us they were happy with the care they received and said they were well looked after. We saw that people had prompt access to any medical or other health related support as and when required and that their care was delivered in accordance with their care plan. People looked well dressed and content. Staff supported people in a patient, unhurried manner and people looked relaxed and comfortable in the company of staff. Staff we spoke with had an understanding of people’s needs, preferences and life prior to coming into the home.

Staff were recruited safely and the number of staff on duty was sufficient on the days we visited. Staff were seen to be confident in their job role, work well together as a team and told us they felt supported by the manager. Records showed that staff had received the training they needed to meet people’s needs.

People said they felt safe at the home and had no worries or concerns. Staff had received safeguarding training and demonstrated an understanding of safeguarding when asked. We saw that safeguarding incidents were reported to and investigated by the Local Authority to protect people from risk. Some of these incidents had not been reported to The Care Quality Commission.

Accident and incidents were appropriately monitored and referrals made to the falls prevention team when necessary. There were systems in place to ensure that the risk of Legionella in the home’s water system was managed and there were a range of health and safety checks in place that ensured the home’s equipment and environment was safe. Other aspects of service management required improvement.

For example, the use of poor moving and handling techniques had not been picked up and addressed by the manager or provider. There were no management systems in place to monitor staff supervision and appraisal and the way in which this support was provided did not comply with the provider’s policy.

The provider’s medication policy was not consistently followed and medication audits were meaningless and ineffective in picking up stock discrepancies, administration errors and the disorganised way in which medication was accounted for.

The provider’s complaints policy did not give people clear information on how to make a complaint or who people should complain to. The manager told us no formal complaints had been received since our last inspection in 2013 but shortly after our visit however we received a complaint about the provider. We reviewed the provider's response to this complaint and found that the wording of the provider's response was not appropriate.

People’s views on the quality of the service had been sought with positive results.

inspected. We used the information to answer the five questions we always ask;

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well led?

Is the service safe?

People were cared for in an environment that was safe. The home was seen to be clean and hygienic. Equipment at the home was well maintained and serviced regularly. There were enough staff on duty to meet the needs of the people living at the home and a member of the management team was always available on call in case of emergencies.

Staff personnel records we looked at for training, supervision and appraisal. All staff were up to date with their training and told us they were supported by the management team.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. While no applications had been made by the home, proper policies and procedures were in place. Staff were trained to understand when an application should be made, and how to submit one.

Is the service effective?

People told us that they were happy with the care and their needs were met. It was clear from our observations and from speaking with staff that they had a good understanding of people's care and support needs and knew them well. One person told us. "The staff are nice here". Staff had received training to meet the needs of the people living at the home.

Is the service caring?

We spent time in all areas of the home where we observed staff to be kind and patient to the people who lived there. Care staff and nursing staff were patient with people, asking them what they wanted and not telling them, but encouraging them in the right direction. One relative told us "It's a caring place and my relative is looked after by staff ".

Is the service responsive?

People's needs were assessed before they moved into the home. A relative told us that all staff were very attentive and understood what was important to their relative. Records confirmed people's preferences, interests, aspirations and diverse needs were recorded and care and support provided in accordance with people's wishes. People had access to activities that were important to them and were supported to maintain relationships with their friends and relatives.

Is the service well led?

Staff had a good understanding of the ethos of the home and quality assurance processes were in place. A relative told us they had completed a customer satisfaction survey, and if they were unhappy with anything staff would always listen. Staff told us they were clear about their roles and responsibilities. They said the management team always consulted with them before implementing changes to the management of the home and their views were taken into consideration. Staff said "We provide good care and at Homecrest".

We pathway tracked the records of three people and saw details of discussions with health and social care practitioners such as the falls team, speech and language therapists and GPs recorded in their care records. Staff we spoke with told us they had a good relationship with other professionals who came to visit which meant that a holistic approach was taken to the care provided.

We saw there was a process for ordering, checking and returning medications and we observed medication being administered by staff who were appropriately trained. The manager made sure that staff employed at the home had the appropriate characters and skills required to undertake the role. There was a complaints procedure to follow, which people were aware of and we found that records were maintained appropriately with clear instruction to staff on how each person's care needs should be met.

'It's fantastic', 'Brilliant here', 'They are absolutely wonderful'.

We found evidence that relatives of people who used the service were involved in deciding their care and treatment and were able to make choices in every day living activities. There were plenty of activities that people enjoyed organised by the activity coordinator and included external entertainers, exercise and poetry groups.

We saw that people were well cared for and treated with dignity and respect. People's needs were assessed, planned and reviewed. We found that the provider monitored the service and gained views on the service from relatives and from people who used the service.