Harlington House

Harlington House is a residential care home providing personal care. The service is registered to support up to 17 people with mental health needs or learning disability. The home is divided into 2 areas; Harlington House, which is a 3 storey older detached building containing individual flats, and the Lodge on the same site, which is a more modern building and has 2 floors. At the time of our inspection there were 12 people using the service.

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

Right Support: Staff supported people to achieve their aspirations and goals. Staff supported people with their medicines in a way that promoted their independence and achieved the best possible health outcome. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Right Care: Risks associated to people’s health were not always effectively managed. Overall, people’s care, treatment and support plans reflected their range of needs and this promoted their wellbeing and enjoyment of life. Staff understood how to protect people from poor care and abuse. The service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it. The service had enough appropriately skilled staff to meet people’s needs and keep them safe.

Right Culture: Systems to identify risk were not always effective and this meant there was aspects of people’s health which were not monitored completely. Staff knew and understood people well and were responsive, supporting their aspirations to live a quality life of their choosing. The manager worked hard to instil a culture of care in which staff truly valued and promoted people’s individuality, protected their rights and enabled them to develop and flourish.

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

Rating at last inspection and update

The last rating for this service was inadequate (published 8 June 2022) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found some improvements had been made, the breaches had been met in relation to safe care, person-centred care and staffing. Further work was needed in relation to good governance and the provider was found to still been in breach of this regulation.

This service has been in Special Measures since 8 June 2022. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We carried out an unannounced comprehensive inspection of this service in January 2022. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve. We undertook this focused inspection to check they had followed their action plan and to see if they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Responsive and Well-led which contain those requirements.

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.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from inadequate to requires improvement. This is based on the findings at this inspection.

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

Enforcement and Recommendations

We have identified breaches in relation to 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 2 recommendations to the provider regarding safe recruitment and medicines.

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.

About the service

Harlington House is a residential care home providing personal care. The service is registered to support up to 17 people with mental health needs or learning disability. The home is divided into two areas; Harlington House, which is a three storey older detached building containing individual flats, and Harlington Lodge on the same site, which is a more modern building and has two floors. At the time of our inspection there were 12 people using the service.

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

The quality and safety of the service had deteriorated since our last inspection which showed the provider was unable to make and sustain improvements to benefit people. The lack of provider and management level oversight meant previously demonstrated standards and regulatory compliance had not been maintained. The provider's systems and processes designed to identify shortfalls, and to drive improvement were not effective and had not identified the concerns we found.

While people told us they felt safe, the risks associated with people’s care and environment had not been adequately identified, assessed or managed. This placed people at risk of harm. Staff had not always had sight of individual risk assessments.

People were not supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible. Relatives did not feel involved in their relative’s care and felt that communication from the service was poor. We found that there were blanket decisions and policies in place which had not considered people’s personal choice.

We found that there were not always sufficient staff available to meet people’s needs as assessed by commissioners. We found that care plans did not clearly outline how people’s care should look and did not guide staff or promote best practice. We found that staff were not always adequately trained to carry out their responsibilities or manage the risks identified.

Staff were safely recruited. Staff told us they found the acting manager approachable and fair. Staff felt supported and liked working at the service. Staff had good knowledge of policies including safeguarding.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

Based on our review of safe, responsive and well led; the service was not able to demonstrate how they were meeting some of the underpinning principles of Right support, right care, right culture. The staffing levels did not always allow for people to have care which maximised choice, control and independence.

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 requires improvement (March 2021). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.

Why we inspected

As part of CQC’s response to the COVID-19 pandemic we are looking at how services manage infection control and visiting arrangements. This was a targeted inspection looking at the infection prevention and control measures the provider had in place. We also asked the provider about any staffing pressures the service was experiencing and whether this was having an impact on the service.

When we inspected and found there was a concern with visiting processes and cleanliness, so we widened the scope of the inspection to become a focused inspection which included the key questions of safe and well-led.

Enforcement and Recommendations

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 monitor the service and will take further action if needed.

We have new identified breaches in relation to person centred care at this inspection.

We have identified continued breaches in relation to managing risks effectively, managing the spread of infection and good governance. We also identified a breach in relation to staffing at this inspection. We have issued the provider a warning notice in relation to these breaches.

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 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.

The overall rating for this service is ‘Inadequate’ and the service is therefore 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.

Harlington House is a residential care home providing personal care to 14 people, at the time of the inspection. The service is registered to support up to 17 people with mental health needs or learning disability. The home is divided into two areas; Harlington House, which is a three storey older detached building containing individual flats, and Harlington Lodge on the same site, which is a more modern building and has two floors.

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

Safe infection prevention and control (IPC) practices were not in place. IPC and COVID-19 policies were not regularly reviewed to reflect government guidance. IPC practices overall required further improvement. The provider took measures to improve these areas following our inspection.

Risks to people were not always managed effectively. Staff were not aware of individualised risks to people and records did not provide robust guidance putting people at increased risk of harm.

Medicines were not always managed safely. Medicines were not stored appropriately and records relating to medicines were not always accurately completed.

Systems in place to monitor the service had not been effective as they had failed to identify and address areas that required improvements. Records were not always accurate and up to date.

People were safeguarded from the risk of abuse. The service worked in partnership with relevant authorities and health professionals to keep people safe.

There was a positive culture at the service. People living there were happy. People and staff were involved in making changes to improve the service.

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

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the guidance CQC follows to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

The service was able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture. The model of care and setting maximised people’s choice, control and independence. People’s dignity, privacy and human rights were respected. They were encouraged by staff to lead inclusive and empowered lives.

Rating at last inspection

The last rating for this service was good (published on 18 June 2018).

Why we inspected

This inspection was prompted through our intelligence monitoring system. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. 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 coronavirus and other infection outbreaks effectively.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection. 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 that the provider needs to make improvement. Please see the safe and well-led sections of this full report. The provider has taken some action since the inspection to mitigate risks.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Harlington House on our 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.

We have identified breaches in relation to safe care and treatment and good governance at this inspection.

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 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.

We found the following examples of good practice:

• The provider had made good improvements to infection prevention and control arrangements since our last inspection in December 2020. They had worked with local infection prevention and control specialists and acted on their recommendations and advice.

• Appropriate personal protective equipment (PPE) was used by staff, and there were safe arrangements for the storage and disposal of PPE.

• Changes had been made to the running of the home and deployment of staffing. These changes had helped to reduce the risk the risk of cross infection and allowed for better social distancing where possible.

• The service followed government guidance in relation to new admissions to the care home, and staff and residents had access to regular testing for coronavirus.

At the time of this inspection there were 13 people using the service.

The inspection was unannounced and took place over two days on 10 and 12 April 2018. At the previous inspection in November 2016 the service was rated Requires Improvement. There was a breach of legal requirements because records were not stored securely, some documentation could not be located and quality assurance audits were not always effective in ensuring improvements were made promptly. At this inspection we found the provider had made sufficient improvement to meet legal requirements and was now rated Good overall.

The provider is required to have a registered manager as a condition of their registration and there was a registered manager in post. They had been registered with CQC since September 2017. 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.

There were systems in place to assess and minimise risk to people, whilst respecting people’s individual choice and wishes. Staff received training in safeguarding vulnerable adults and demonstrated a good understanding of safeguarding procedures and how to raise concerns. There were systems to ensure people received their medicines safely, but there were anomalies in the recording of one person’s insulin injections.

Improvements had been made to the effectiveness of the cleaning systems in place to ensure appropriate standards of hygiene were maintained.

The provider followed robust systems for the recruitment of staff and was taking appropriate steps to ensure the suitability of workers. There were sufficient staff to keep people safe and meet their needs. Staff received an induction, training and regular supervision to give them the skills they needed to support people.

People were supported to have maximum choice and control over their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. The service was meeting the requirements of the Deprivation of Liberty Safeguards (DoLS).

People told us they were happy with the meals available and had opportunity to be involved in preparing their own food where they were able to. Staff monitored people’s weight and nutritional needs. People were supported to maintain good health and access healthcare services, but we found some records in relation to people’s healthcare needs lacked clarity.

People’s privacy and dignity was respected, and we observed staff were attentive, caring and respectful in their interactions with people. It was evident staff knew people well. People were involved in decisions about their care.

Detailed care plans were in place to give staff the guidance they needed to support people. Care plans were regularly reviewed.

There was a complaints procedure in place and records showed us that any complaints and concerns were acted on. People told us they would feel able to raise any concerns.

The registered manager and provider conducted a range of audits in order to monitor the quality of the service provided and were used to drive improvement. However, they had not been effective in identifying and addressing the record keeping issues we found in relation to people’s healthcare needs in some care files. Statutory notifications of DoLS authorisations had not been submitted to CQC in a timely manner.

The inspection took place on 22 and 23 November 2016. The inspection was unannounced.

At an inspection in November 2014, we asked the registered provider to take action to make improvements with regard to quality assurance, consent to care, staffing, supporting staff and record keeping as they were not meeting legal requirements at that time. The registered provider wrote to us to say what they would do to meet the legal requirements in relation to the breaches of regulation. At an inspection on 30 April 2015 we found that the registered provider had taken action to address the breaches and was meeting legal requirements. The service was rated ‘Requires Improvement’ overall.

At the time of our inspection on 22 and 23 November 2016 there were ten people who used service, who had a learning disability and/or mental health or physical health needs.

The registered provider is required to have a registered manager in post and there was no registered manager at this service. This meant that we could not rate the question: Is the service well-led? any higher than requires improvement. The previous registered manager had left in April 2016 and a new manager had started in post approximately two months prior to our inspection, but they had yet to submit an application to register with the Care Quality Commission (CQC). 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.

There were effective systems in place to help make sure people who used the service were protected from the risk of abuse. Staff demonstrated a good understanding of their responsibilities in relation to reporting safeguarding issues.

People’s needs were assessed and risk assessments were in place to reduce risks and prevent avoidable harm. There were systems to ensure people received their medicines safely, but there was some inconsistency in the registered provider's records relating to prescribed creams.

There were cleaning schedules in place, but some areas of the home had not been cleaned effectively and we have made a recommendation that the registered provider takes action to ensure appropriate standards of hygiene are consistently maintained.

The registered provider had a safe system for the recruitment of staff and was taking appropriate steps to ensure the suitability of workers. There were sufficient numbers of trained, competent staff to keep people safe and meet their needs, although the registered provider had been relying on regular agency staff in order to maintain staffing levels.

Staff received an induction, training and supervision to enable them to provide effective care for people.

Staff were able to demonstrate an understanding of the importance of gaining consent before providing care to someone and we found the service to be meeting the requirements of the Deprivation of Liberty Safeguards (DoLS).

People told us staff were caring and we observed many examples of positive, warm and friendly interactions between people and staff. People were involved in decisions about their care and we observed people being offered choices about their daily routines, what they wanted to eat and what they wanted to do with their day. People’s privacy was respected.

Care plans were developed in order to give staff the guidance they needed to support people and provide a personalised service. Care plans were regularly reviewed and most were appropriately updated. Staff we spoke with were knowledgeable about people’s needs and preferences.

We found that people were supported to maintain good health and access healthcare services. People told us they were happy with the quality and choice of food available, and some people prepared their own meals. Care plans contained information about people’s nutritional needs and preferences, and people’s weight was monitored. We did however find one person’s care plan did not clearly reflect all action that was currently being taken in relation to their fluctuating weight. The manager agreed to address this.

There was a complaints procedure in place and people were able to make suggestions and raise concerns or complaints but record keeping in relation to complaints was poor. We were told no formal complaints had been made in the year prior to our inspection, but the complaints file and records of minor concerns and issues raised during the year could not be located. Improvement was required in this area so that the registered provider could be sure that all concerns and complaints were consistently and appropriately acted on.

There had been a number of management changes over the year prior to our inspection, which had been unsettling for staff, but staff said the new manager was approachable and supportive and we found there was a positive and person centred culture at the home.

The registered provider conducted a range of audits in order to monitor the quality of the service provided and most issues identified in audits were addressed, although we did find some actions that had not been completed. There were also a number of other issues we picked up during our inspection that showed that the registered provider needed to be more proactive in driving improvement. Collectively these issues were a breach of legal requirements in relation to quality assurance and record keeping.

The safety of people living at Harlington House was promoted as the service took prompt action to manage and report any allegations of abuse. However, the service did not operate in a way that respected people's human rights and dignity. Several people told us they did not like living there.

The service was not safe, clean and hygienic. Furniture was not well maintained and the overall environment was not monitored. This put people at unnecessary risk.

When people displayed behaviours that distressed other people living there the staff did not always manage the situation in an effective way. This meant that the atmosphere was not calm and relaxed and people were at greater risk of becoming frustrated and upset.

Systems and procedures related to medicines management were not robust. This meant there was a risk that people may not get their medication in a safe way, and as prescribed. This placed people at risk of harm.

Procedures were not in place to help people when they did not want the care and support offered to them. There were no systems to ensure that action was taken and guidance sought, when people regularly declined the support offered to them.

There was a lack of direction and leadership at the service. Staffing rotas were not completed to reflect essential regular tasks like shopping, and other needs, like healthcare appointments. Insufficient staffing levels places people at increased risk of harm.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to respecting and involving people, the environment and infection control practices, care and risk management, staffing and medicines.

Is the service effective?

Whilst the service displayed information about independent advocacy services, this was not always in a format that people could understand. Therefore some people living at Harlington House may not know this service was available.

We saw some evidence that people had been included and consulted about their care and support needs, in that they had added their signature to the records. However, those we looked at were not in a format that could easily be understood by someone with a learning disability. This made it more difficult for people to feel involved and included in the writing of their care plan.

We saw that whilst healthcare professionals were consulted, when people were feeling unwell, the guidance provided was not always followed in a timely way. This could affect people's well-being, general health and ability to be independent.

People's plans of care were not always being followed. People's needs, choices and wishes were not being respected. Procedures were not in place to ensure that guidance was sought when people did not want their agreed support.

People's needs had not been considered in the way the service was operating. There were no effective measures in place to ensure the environment was calm and relaxing. There was no pride in living there because the environment was dirty and uncared for.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to respecting and involving people, the environment and infection control practices, and care and risk management.

Is the service caring?

People said they liked practically all the staff who worked there. They said they were kind and friendly. One person said 'The staff are nice. I'm very happy here.' However, another told us 'The staff don't talk to me that much. They're all too busy. I get frustrated when they don't talk to me.'

We saw people were shown kindness however, whilst staff tried to help people, this was not always in the most appropriate manner. Staff did not encourage people by working alongside them, or by asking the individual to do small tasks for themselves. This meant people were not challenged to learn new skills or to have more interesting lives.

People in some cases looked uncared for. Their clothes were stained. Some men were unshaven. Whilst staff were promoting people's independence the care records did not indicate that they were helping people who either did not want or could not manage aspects of their care themselves.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to involving people in planning and managing their care.

Is the service responsive?

The provider is part way through consulting with people, their families and with visiting professionals about the service they provide. Their feedback will help to indicate whether people living there and stakeholders want to see changes in the way the service was operating.

There were not robust records to demonstrate that people were leading interested and varied lives. One person was looking forward to a holiday in Cornwall. One person said 'I like to go out, but sometimes the staff are sick, so I can't go.'

The processes to show that people's views were actively sought about their care, their meals, weekly activities and general day to day life needed improving. People's rooms looked at were not individualised in that they did not reflect their preferences and interests.

Although the service had a complaints policy this was not always in a format that people could understand. The service had a complaints policy though complaints were not always taken seriously and looked into properly.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to involving people in decisions about their care, in staffing and in managing complaints.

Is the service well-led?

Whilst the provider had a senior management team and systems to monitor the quality of the service, we saw little evidence that these were being completed. This meant the quality of the service was not being kept under review.

There was a lack of leadership, organisation and work allocation. The staff lacked direction and they were unaware of their roles and responsibilities. This meant no-one took responsibility for failures and failings. There were no processes in place to develop best practise that could be used to enable the service to be continually improving.

The service did not have a system to learn from accidents, incidents, safeguarding concerns and medication errors. There was no effective system to continually review these incidents. There was no evidence of analysis of these events, or action plans to show what the service was doing to minimise the risk of a similar event happening again. This meant there was no evidence that the service learned from these events.

Whilst the provider had identified that more staff were needed there was no system in place to monitor the staff competencies and ensure staff were receiving training in a timely way. Staff were not supervised to check that their skills and behaviours were in line with the ethos of the service.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to quality assurance, and the improvements they will make in relation to the management of the service.

People were asked for their consent and everybody worked together to assist people to learn how to manage risks associated with everyday living. We saw that there were opportunities for people who used the service to make choices and they had a say in how their treatment or care was delivered. We found that care and treatment was personalised and people took part in a range of activities in the community.

Throughout our inspection we observed there were sufficient numbers of staff available to support people in their chosen activities. There were good interactions between the members of staff and people who used the service. We saw that people who used the service were relaxed in the care of the staff. A healthcare professional told us staff listened to advice and that they were adaptable. The manager was singled out for mention by most of the people we spoke with. One person said 'I would go to (the manager); she sorts everything out for me.' Another person said 'I have no concerns when (the manager) is here. She is really great.'

Effective systems were in place to monitor the quality of the service and promote people's safety and wellbeing in a well maintained home.

People who used the service told us 'It's okay living here my key worker talks to me about what is happening in my life'. Another person said 'I moved upstairs to be with the other guys. Staff asked me if I wanted to move'

During our inspection we spoke with relatives and they told us that staff had worked with them to ensure that the person who used the service was properly supported. They appreciated the effort staff made to ensure their relative had the best support possible.

Staff were aware of the different types of abuse and said they were confident they would be able to identify any signs of abuse in people who used the service.

People told us that if they had a complaint they would tell a member of staff or the manager. They also told us that there were regular house meetings where they could all discuss any concerns they had. One person said "The staff take time to talk to you" and another said "I talk to my key worker if I am unhappy." Relatives spoken with told us that when they had made a complaint it had been dealt with appropriately and the manager always took time to let them know what was happening in relation to their relative.