Hawkinge House

Hawkinge House is a residential care home providing personal and nursing care for up to 146 people. The service also provides care for other service user groups, such as supported living and personal care. People were living with a range of complex health needs, including brain injuries, diabetes and those living with dementia. Hawkinge House also provided short term support for people after discharge from hospital and before either returning home or moving to longer term accommodation.

At the time of our inspection there were 92 people using the service. Some people rented their accommodation and had tenancy agreements with Hawkinge House Limited. These people could choose which organisation provided their care, but they all chose to receive their care from staff employed by Hawkinge House. Everyone living at the service was entitled to the same level of 24-hour care, therefore we included everyone living in the service in our inspection. The accommodation was arranged across three floors, with lift access to the upper floors.

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

At the last inspection people and their relatives told us that communication was poor. For example, emails were not always responded to and it was difficult to get to talk to the right person on the phone. Some relatives told us they hadn’t been informed about changes in their relative’s care or condition. At this inspection, relatives acknowledged there had been some improvement in communication, but this could still be improved. The service had a home improvement plan in place and the management team were working through this.

There were enough staff deployed to provide safe care for people and the provider was in the process of recruiting additional staff to support and improve social engagement and offer a wider range of activities for people.

People told us they felt safe living in the service and liked living there. Relatives told us their loved ones were safe living in Hawkinge House. One relative said, “We couldn’t ask for anything better. Staff are polite, friendly, caring and always smiling.”

Risks to people were managed. The provider had appropriate infection control measures in place and medicines were managed safely. Risk assessments and care plans had been recently reviewed and were up to date. Staff knew the people they were supporting well and had read the care plans. Staff had attended additional training in person centred care.

The provider had quality assurance processes in place and had introduced additional audit activity to monitor the quality of the service provided. A recent survey had been sent to people and relatives, but results had not been received or analysed at the time of our inspection.

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.

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 (published 26 January 2022) and there were two breaches of regulation. The provider completed an action plan after the last inspection to show what they would and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 23 November 2021. Two 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 person centred care and good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm 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.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has remained 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 Hawkinge House on our website at www.cqc.org.uk.

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.

We undertook this inspection at the same time as CQC inspected a range of urgent and emergency care services in Kent and Medway. To understand the experience of social care providers and people who use social care services, we asked a range of questions in relation to accessing urgent and emergency care. The responses we received have been used to inform and support system wide feedback.

Follow up

We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The area allocated as the designated setting for the admission of people from hospital who had tested positive for COVID-19, could accommodate 17 people. There were three people living in that area at the time of the inspection, but there were plans in place to relocate them to another part of the service with their permission.

We found the following examples of good practice.

The designated area had a separate entrance for people and staff. This meant that staff working in the designated setting did not have to go through any other part of the service at the start and end of their shifts. The separate entrance for people meant that people who may be at risk of transmitting the COVID-19 infection to others would not be accessing any other area of the service.

A separate staff team was allocated to the designated setting to prevent any cross contamination. This included nurses, care staff and housekeeping staff. Staff had their own changing room and rest and refreshment facilities within the designated area. Uniforms were provided, staff changed on site and uniforms were laundered on site.

The designated setting was self-contained with its own treatment room, medicines trolley and other equipment that may be required. Bedrooms had their own private bathrooms and there was an outdoor balcony attached to the unit.

The service looked clean and had hand sanitising areas throughout. The service had enough personal protective equipment (PPE) to meet current and future demand and staff were using PPE correctly.

We were assured that this service met good infection prevention and control guidelines as a designated care setting.

Hawkinge House is a residential care home providing personal and nursing care for up to 115 people. The service is also registered as a supported living service, extra care housing service and domiciliary care service. People were living with a range of complex health needs, including those living with dementia, brain injuries or diabetes.

At the time of our inspection there were 109 people using the service. People using the supported living service rented their accommodation and had tenancy agreements with Hawkinge House Limited. These people could choose what organisation provided their care, but they all chose to receive their care from staff employed by Hawkinge House. Everyone living at the service was entitled to the same level of 24-hour care, therefore we included everyone living in the service in our inspection.

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

The provider had quality assurance processes in place but lacked robust mechanisms to address shortfalls and learn lessons to drive improvement. Plans were in place to make positive changes, but these had not yet been embedded into the service.

Risks were not always safely managed as some assessments and care plans were not up to date. Care was not always personalised, and staff did not always have detailed knowledge of the people they were supporting. One person told us, “I have heard of a care plan, but I’ve never seen it.” Handover notes were not consistently read by staff.

There were not always enough staff deployed to meet peoples’ needs and ensure people were not at risk of social isolation. There had been some changes within the staff teams, which had a negative impact on peoples’ lives. People and their relatives consistently told us there was not enough going on to keep them engaged, especially for those people who needed to be nursed in bed. One relative said, “They don’t seem to want to do anything with [relative].”

People told us they felt safe living in Hawkinge House and were generally happy living there. One person said, “I feel safe living here, this place saved my life.” Individual staff were described as kind and caring, and peoples’ privacy was respected. One person said, “They are very nice and helpful.” Staff were recruited safely and had received training. Medicines were managed safely.

The service had a new manager who was aware of shortfalls in the service and was working through these with senior managers and the local authority.

We have made a recommendation about the management of records in relation to complaints.

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.

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 31 December 2019).

Why we inspected

This inspection was prompted by our data insight that assesses potential risks at services, concerns in relation to aspects of care provision and previous ratings. As a result, we undertook a comprehensive inspection. This enabled us to look at the concerns raised and review the previous ratings.

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.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, responsive and well led sections of this full report. The overall rating for the service has changed from good 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 Hawkinge House on our website at www.cqc.org.uk.

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.

Hawkinge House is a service providing personal and nursing care for up to 146 people. The service is provided in one purpose built building set over three floors with a communal lounge, seating areas and dining area on each floor.

Some people living at the service had tenancy agreements with the registered provider and as such fell under the regulated activity of personal care. At the time of our inspection 112 people were living at the service. Of these, 74 people received accommodation and personal care as one contractual arrangement; 38 people had a tenancy agreement and in receipt of personal care within their home. The registered manager confirmed that everyone living at the service was entitled to the same level of 24-hour care, therefore we have included everyone living at the service in our inspection.

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

People and their relatives told us they were safe and well cared for at the service. One person told us, “There’s no problem at all, I haven’t got any problems. All the people, all the staff are all very friendly and I am very happy. I’d speak to the manager if ever there was a problem”. Individual risks were assessed, and guidance was in place for staff to minimise risks. Staff understood they had responsibilities in relation to safeguarding people. People could be assured their medicines were safely managed and given as prescribed. Infection control procedures were effective and adhered to by staff. Accidents and incidents had been reviewed to learn lessons and to prevent a re-occurrence. There were enough staff to provide safe care and robust recruitment procedures made sure new staff were recruited to ensure they were suitable for their role.

People, staff and relatives told us the management team was approachable and they felt listened to. There was a focus on a person-centred culture. Staff liaised closely with other professionals to make sure people’s needs were assessed and met. Relatives were kept informed of any concerns with their loved ones care. Regular audits were completed to monitor the quality and safety of the care provided. These were used to inform senior management and the board to support continuous improvement.

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 (report published 31 December 2019).

Why we inspected

We had concerns in relation to safeguarding incidents and complaints the service had received. 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 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.

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.

The overall rating for the service has remained good. 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 Hawkinge House on our website at www.cqc.org.uk.

Follow up

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

The proposed designated care setting was on a separate floor of the pro-active assessment unit. Hawkinge House is registered to support up to 115 people. At the time of inspection there was no one living in the designated care setting but there were people living in other areas of the home.

We found the following examples of good practice.

¿ The pro-active assessment unit had its own dedicated registered manager who was not responsible for care in other parts of the complex. This registered manager, alongside a management and nursing team were responsible for the designated care setting.

¿ The designated care setting was separate from the rest of the home and the registered manager had thought about how the setting would interact safely with other areas of the home.

¿ Bedrooms on the designated care setting were self-contained. There were communal areas large enough to enable people to social distance.

¿ Staff assigned to work in the designated care setting would not access the rest of the home or come into contact with other staff at the home.

¿ The home was participating in weekly testing for staff.

We were assured that this service met good infection prevention and control guidelines as a designated care setting.

Further information is in the detailed findings below.

Hawkinge House is registered as a community healthcare service, domiciliary care service, extra-care housing service, supported living service and a care home with nursing.

A community healthcare service provides nursing and other clinical resources to people who live in their own homes. A domiciliary care service provides personal care to people living in their own homes. A supported living service provides care and support to people living in supported living settings so that they can live as independently as possible. Under this arrangement people's care and housing are provided under separate contractual agreements.

An extra care housing service provides care and support to people living in 'extra care' housing. Extra care housing is purpose built or adapted single household accommodation in a shared site or building. The accommodation is bought or rented and is the occupant's own home. In both supported living services and extra care housing services people's care and housing is provided under separate contractual agreements.

In a care home with nursing service people receive accommodation, nursing and personal care as a single package under one contractual agreement.

Hawkinge House is registered to provide accommodation, nursing and personal care for 115 people. It can accommodate younger adults, older people and people who live with dementia. It can also provide care for people who need support to maintain their mental health and/or who have physical adaptive needs.

At the inspection there were 81 people living in Hawkinge House of whom 15 were using the care home with nursing service. They were funded by a health authority as they needed complex nursing care.

The remaining 66 people used the supported living service, rented their accommodation and had tenancies with Hawkinge House Limited. These people could choose which provider delivered their care. All the people using the supported living service had chosen to receive their nursing and personal care from nurses and care staff employed by Hawkinge House Limited. This provision was made by Hawkinge House Limited acting as a domiciliary care service.

At the inspection no-one living in Hawkinge House was using it as a community healthcare service or an extra-care housing service.

The accommodation was provided on three self-contained floors comprising a number of bedrooms, communal bathrooms and lounges. Each person had their own bedroom and private bathroom. There was no physical separation between the accommodation used for the supported living service and the care home service. A person using the care home with nursing service might have their bedroom next door to a person using the supported living service and both people may use the same communal lounge.

People's experience of using the service and what we found

People and their relatives were positive about the service. A person using the supported living service said, “I like the staff well enough and they’re very helpful.” A relative said, "The staff are excellent, caring and loving to the residents.”

People were safeguarded from the risk of abuse. People received safe care and treatment in line with national guidance from nurses and care staff who had the knowledge and skills they needed. There were enough nurses and care staff on duty and safe recruitment practices were in place. People were helped to take medicines in the right way and lessons had been learned when things had gone wrong. Hygiene was promoted to prevent and control infection and people had been helped to quickly receive medical attention when necessary.

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

The accommodation was designed, adapted and maintained to meet people’s needs and expectations.

People were treated with kindness and compassion, their privacy was respected and confidential information was kept private.

People were consulted about their care and had been given information in an accessible way. People were supported to pursue their hobbies and interests. There were arrangements to quickly resolve complaints. People were treated with compassion at the end of their lives so they had a dignified death.

There was no registered manager. Some people had not been fully consulted about the development of the service. Quality checks had been completed, good team work was encouraged and joint working was promoted.

For more details, please read 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 24 April 2019).

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

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

Hawkinge House is registered as a community healthcare service, domiciliary care service, extra-care housing service, supported living service and a care home. A community healthcare service provides nursing and other clinical resources to people who live in their own homes. A domiciliary care agency provides personal care to people living in their own homes. A supported living service provides care and support to people living in supported living settings so that they can live as independently as possible. Under this arrangement people's care and housing are provided under separate contractual agreements. An extra care housing service provides care and support to people living in 'extra care' housing. Extra care housing is purpose built or adapted single household accommodation in a shared site or building. The accommodation is bought or rented and is the occupant's own home. In both supported living services and extra care housing services people's care and housing is provided under separate contractual agreements.

• Hawkinge House is registered to provide accommodation, nursing and personal care for 115 people. It can accommodate younger adults, older people and people who live with dementia. It can also provide care for people who need support to maintain their mental health and/or who have physical adaptive needs.

• There were 76 people living in the service at the time of our inspection. Sixty-six people who were living in the service at the time of our inspection had rented their accommodation in Hawkinge House. All these people received their nursing and personal care from members of staff employed by Hawkinge House Limited who was the registered provider.

Ten people received both their accommodation and care as part of a single package that was also delivered by the registered provider. Each person who lived in the service had their own bedroom with a private bathroom.

Rating at last inspection: ‘Inadequate’ (report published December 2018).

Why we inspected: At the last inspection on 10 September 2018 and 11 September 2018 the overall rating of the service was, ‘Inadequate’ and was placed into ‘special measures’. There were eight breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. There were serious shortfalls in the arrangements that had been made to provide people with safe care and treatment. These oversights included the arrangements made to prevent avoidable accidents.

Suitable systems and processes were not in place to supervise the operation of the service so that people consistently received the high-quality care they needed and had the right to expect. Robust arrangements had not been made to reliably safeguard people from situations in which they may be at risk of experiencing abuse.

Sufficient care staff had not always been deployed to enable people to promptly receive all the care they needed. Suitable background checks had not always been completed before new members of staff were appointed.

People had not always received care that promoted their dignity when they became anxious. People had not always received person centred care. This was because they had not always been given information in an accessible way to enable them to be fully involved in reviewing decisions made about their care. In addition to this, they had not always been fully supported to pursue their hobbies and interests.

Complaints had not been managed in a robust way that provided people with reassurance and enabled the service to learn from mistakes that had been made.

We found one breach of the Care Quality Commission Registration Regulations 2009. This was because the registered provider had failed to submit a statutory notification in line with our guidance.

• We told the registered provider to send us each month an action plan stating what improvements they had made and intended to make to address our concerns. The registered provider complied with this requirement.

• At this inspection on 7 March 2019 and 8 March 2019 we found that sufficient progress had been achieved to meet all the breaches of regulations.

• Sufficient provision had been made to provide safe care and treatment. New and better organised arrangements had been made to safeguard people from situations in which they may experience abuse. There were enough nurses and care staff on duty. Suitable arrangements were in place to recruit and select new members of staff.

•Strengthened arrangements had been made to deliver person-centred care. Suitable provision had been made to investigate and quickly resolve complaints. The systems and processes used to assess and monitor the operation of the service had been strengthened. Statutory notifications had been submitted to us in the correct way.

• At this inspection we found that in each key question the service now met the characteristics of Requires Improvement. Although progress had been made we need to be reassured that this can be sustained. We also need to know that some remaining shortfalls will be addressed.

• 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.

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

What life is like for people using this service:

Our other findings were as follows:

• Although the service was clean and hygienic improvements were needed to ensure that this remained the case. People and their relatives had given their consent to the care and treatment provided. However, these agreements had not always been well recorded. Although most people had been supported to access a range of healthcare services one person had experienced a delay in medical attention being requested.

• Medicines were managed safely and care was delivered in line with national guidelines. People were supported to eat and drink enough. People had been supported by relatives to make decisions about things that were important to them.

• Equality and diversity had been promoted and people had been supported at the end of their life to have a comfortable, dignified and pain-free death.

• Regulatory requirements were met and the manager was working in partnership with other agencies to support the development of joined-up care.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit in line with our re-inspection programme. If any concerning information is received we may inspect sooner.

Hawkinge House is registered as a community healthcare service, domiciliary care agency, an extra-care housing service, a supported living service and a care home. A community healthcare service provides nursing and other clinical resources to people who live in their own homes. A domiciliary care agency provides personal care to people living in their own homes. A supported living service provides care and support to people living in supported living settings so that they can live as independently as possible. Under this arrangement people's care and housing are provided under separate contractual agreements. An extra care housing service provides care and support to people living in 'extra care' housing. Extra care housing is purpose built or adapted single household accommodation in a shared site or building. The accommodation is bought or rented and is the occupant's own home. In both supported living services and extra care housing services people's care and housing is provided under separate contractual agreements. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. In this case the Care Quality Commission regulates both the premises and the care provided, and both were looked at during this inspection.

Hawkinge House is registered to provide accommodation, nursing and personal care for 115 people. It can accommodate younger adults, older people and people who live with dementia. It can also provide care for people who need support to maintain their mental health and/or who have physical adaptive needs.

Most of the people who were living in the service at the time of our inspection had rented their accommodation in Hawkinge House. All of these people in practice received their nursing and personal care from members of staff employed by Hawkinge House Limited who was the registered provider. A small number of people received both their accommodation and care as part of a single package that was also delivered by the registered provider.

There were 89 people living in the service at the time of our inspection. The accommodation was provided on four floors called Nightingale, Eden, Phoenix and Jasmine. Each person who lived in the service had their own bedroom with a full ensuite bathroom.

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. In this report when we speak about both the company and the registered manager we refer to them as being, ‘the registered persons’.

At the last comprehensive inspection on 20 July 2017 the overall rating of the service was, ‘Requires Improvement’. We found that there were two breaches of regulations. The first breach was because the registered persons had not reliably ensured that people who lived in the service consistently received safe care and treatment. The second breach was because the registered persons did not have robust systems and processes in place to assess, monitor and improve the quality and safety of the service. This shortfall had resulted in problems in the provision of safe care and treatment not being quickly identified and resolved.

We told the registered persons to send us an action plan stating what improvements they intended to make and by when to address our concerns and to improve the key questions of 'Safe' and ‘Well led' back to at least, 'Good'. After the inspection the registered persons told us that they had made the necessary improvements.

At the present inspection we found that sufficient steps had still not been taken to address either of these breaches. This was because people had not consistently received safe care and treatment. In particular, lessons had not been learned when things had gone wrong. As a result, people had not been fully protected from the risk of injury resulting from accidents and untoward events. Furthermore, the registered persons had still not established robust arrangements to supervise the operation of the service so that people consistently received the high-quality care they needed and had the right to expect.

There were six additional breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because robust arrangements had not been made to reliably safeguard people from situations in which they may be at risk of experiencing abuse. In addition to this, the registered persons had not deployed enough nurses and care staff. Recruitment checks had not been completed in the right way to ensure that only suitable people were employed to work in the service. People had not always received care that was respectful, promoted their dignity and was person-centred. Complaints had not been managed in a robust way that provided people with reassurance. In addition to these shortfalls, there was one breach of the Care Quality Commission Registration Regulations 2009. This was because the registered persons had failed to submit statutory notifications in line with our guidance.

As a result of these continuing and new breaches of regulations 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 registered persons’ registration of the service, will be inspected again within six months. The expectation is that registered persons 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 registered persons 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. When 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 registered persons from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

Full information about the Care Quality Commission’s regulatory response will be added to our report after any representations and appeals have been concluded.

We found an addition shortfall in the service in relation to which we have made a recommendation. This was because nurses had not been fully supported to care in the right way for two people who were at risk of becoming dehydrated.

Our other findings were as follows: There were shortfalls in the maintenance and decoration of the accommodation including the provision that had been made to prevent and control the risk of infection. Medicines were managed safely. Suitable arrangements were in place to obtain consent so that people only received lawful care. People had received coordinated care when they moved between different services and they had been helped to obtain any healthcare they needed. People had been supported to make decisions about things that were important to them. Arrangements had been made to promote equality and diversity. Provision had been made to support people at the end of their life to have a comfortable, dignified and pain-free death.

Nurses and care staff recognised the importance of speaking out if they had concerns about the wellbeing of a person who lived in the service. The registered persons were working in partnership with other agencies to promote the delivery of joined-up care. The quality rating that we gave the service at out last inspection had been displayed in the service and on the registered provider’s website.

The service has a registered manager, who was present throughout the 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 and associated Regulations about how the service is run.

Hawkinge House was last inspected in November 2016 where a number of breaches of the regulations were identified and it was rated Requires Improvement. The provider sent us an action plan to tell us what actions they were taking to implement those improvements. At this inspection we found that changes had been implemented to address the issues and improvements had been made. However, there were a small number of issues which still required further attention.

Accidents and incidents were reported and responded to in most cases. However, there were occasions when responses did not take place in a timely manner.

Management oversight of the service had improved since our last inspection. Most audits and checks had been effective in identifying and remedying shortfalls, however improvement was further input was needed in some areas. Feedback had been sought from people, relatives and staff.

Risk to people had been assessed. Care plans, risk assessments and guidance were in place and gave staff sufficient knowledge to support people in an individual way. Overall, assessed risks to people's health, such as monitoring food and fluid intake were consistent although this continued to require improvement.

The management of medicines had improved, people received their medicines safely. Policies and procedures were in place but on one occasion staff responsible for administering medicines did not follow these.

Staff knew how to keep people safe from abuse and neglect and the manager referred most incidents to the local safeguarding authority. The safety of the premises was assured by regular and routine checks on utilities and equipment. Fire safety had been addressed through training, drills and alarm testing. Maintenance had been carried out promptly when repairs were needed.

People had a choice of nutritious meals, snacks and drinks, and could choose where they would like to eat. Staff encouraged people to eat their meals and gave assistance to those that required it. Some recording of people’s intake needed improvement to ensure it was clear and consistent.

There were enough staff on duty and they had received relevant training and supervision to help them carry out their roles effectively. Staff were observed putting their training into practice in a safe way. A dependency tool had been introduced to enable to registered manager to assure themselves that staffing levels remained adequate. Recruitment files contained all the required information about staff.

A range of professionals were involved in people’s health care and individual plans of care were in place if people had specific health needs like Diabetes, catheters or pressure wounds.

Staff and managers worked within the principles of the Mental Capacity Act 2005 (MCA) which ensured people’s rights and wishes were protected.

Staff treated people with kindness, compassion and respect. Staff took time to speak with the people they were supporting. We saw many positive interactions and people enjoyed talking to the staff. The staff on duty knew the people they were supporting and the choices they had made about their care and their lives.

Care plans had been reviewed since the last inspection, and were increasingly person-centred; they reflected people’s individual preferences and gave staff an understanding of the person. A range of activities were on offer with specific sessions and groups designed for people living with dementia. Staff encouraged people to be involved and feel included in their environment. People's privacy and dignity was respected.

Complaints had been documented and recorded. People and relatives said they knew how to complain if necessary and that the registered manager was approachable.

We found two of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have asked the provider to take at the end of this report.

The service has a registered manager, who was present throughout the 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 and associated Regulations about how the service is run.

Hawkinge House was last inspected in January 2016 where a number of breaches of the regulations were identified and it was rated Requires Improvement. The provider sent us an action plan to tell us what actions they were taking to implement those improvements. At this inspection we found that changes had not been fully implemented to address all of the issues, leaving some people exposed to the risk of harm. Further areas of concern were also identified at this inspection.

There continued to be areas of medicines management that required improvement in order to make them safe. Most people received their medicines when they should. There were continued shortfalls in the recording of transdermal patch administration and recording and in medicines that are prescribed to be taken ‘As required’.

Staffing levels were not sufficient to meet people’s needs; assessed levels were not always available on duty. We found recruitment processes were robust.

Essential training had been completed by the majority of staff, and some staff had completed additional training in some topics. Staff told us they were able to request additional training if they wished to develop a particular area of knowledge. Staff were provided with the opportunity to undertake a qualification relevant to their role to further develop their knowledge.

Most people reported to enjoy the food however we found people’s hydration and nutritional needs continued to be monitored inadequately, placing people at risk of not receiving sufficient amounts to eat and drink. People had access to healthcare services however, a lack of effective recording meant advice was sometimes not followed through by staff.

Complaints and incidents were not consistently recorded and monitored in line with policy.

People were kept safe from abuse as staff were aware of safeguarding procedures and we saw these were followed when abuse was alleged or suspected.

Staff treated people with kindness, compassion and respect. Staff took time to speak with the people they were supporting. We saw many positive interactions and people enjoyed talking to the staff. The staff on duty knew the people they were supporting and the choices they had made about their care and their lives, although this was not always reflected in care plans, where there was little reference to people’s preferences and wishes. Social assistants had developed good relationships with people and ensured that a range of activities were available for people if they wished to participate.

People had a choice of meals, snacks and drinks, and could choose where they would like to eat. Staff encouraged people to eat their meals and gave assistance to those that required it.

Staff understood the basic principles of the Mental Capacity Act and knew how to support people who were not able to make their own decisions. People’s rights were protected.

Most staff reported that they were clear about their roles and felt well supported by the registered manager. Although this was not consistent across all staff. Audits and checks were in place but were not effective in identifying shortfalls or areas for improvement.

We found a number of new and continued breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of this report.

The service has a registered manager, who was present throughout the 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 and associated Regulations about how the service is run.

People were kept safe from abuse as staff were aware of safeguarding procedures and we saw these were followed when abuse was alleged or suspected. Staffing levels were sufficient to meet people’s needs, however we found recruitment processes were not always thorough and robust.

Medicines were stored securely and safely. People received their medicines when they should but there were shortfalls in the recording of topical creams administration and in medicines that are prescribed to be taken ‘As required’.

People enjoyed the food however we found people’s weight and nutritional needs were not being monitored effectively, placing people at risk of not receiving sufficient amounts to eat and drink. People had access to healthcare services however, a lack of effective recording meant advice was sometimes not followed through by staff.

Most staff treated people with kindness, compassion and respect. Staff took time to speak with the people they were supporting. We saw mainly positive interactions and people enjoyed talking to the staff. On occasions we saw some less caring interactions. The staff on duty knew the people they were supporting and the choices they had made about their care and their lives, although this was not always reflected in care plans, where there was little reference to people’s preferences and wishes. Social assistants had developed a good rapport with people and ensured that a range of activities were available for people if they wished to participate. There were less meaningful activities for those who spent most of their time in bed.

People had a choice of meals, snacks and drinks, and could choose where they would like to eat.

Staff encouraged people to eat their meals and gave assistance to those that required it.

Staff had completed training and were able to request additional training if they wished to develop a particular area of knowledge. Staff were provided with the opportunity to undertake a qualification relevant to their role to further develop their knowledge. There were enough staff to meet people’s needs.

Staff understood the principles of the Mental Capacity Act and knew how to support people who were not able to make their own decisions. People’s rights were protected.

Staff were clear about their roles and felt well supported by the registered manager. Audits and checks were in place but were not always effective in identifying shortfalls or areas for improvement.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of this report.

We looked at the answers to five questions: 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?

We viewed all areas of the home, including some of the bedrooms. The home was clean in all areas and provided a pleasant environment for the people who lived there. One person said 'I am very happy with my room'; and another told us 'I have a lovely room'. We saw that some alterations and maintenance work were being carried out to several suites on the ground floor. People living in the home said they had been informed about this. The manager told us that the builders were making sure they provided a safe environment for people living in the home during this work.

We found that the company had comprehensive procedures in place to check that people had consented to the care and treatment provided for them. People who lacked the mental capacity to make decisions about where they lived or the care that they needed had been appropriately supported by their family members or advocates, and by health and social care professionals, to make decisions on their behalf and in their best interests. The manager and staff showed that they understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). The manager said that it had not been necessary to make any applications to deprive someone of their liberty for their own safety.

We talked with some of the staff about safeguarding procedures and they showed that they understood the signs of abuse and knew how to report any concerns or suspicions of abuse. Staff training records confirmed that all of the staff were trained in safeguarding vulnerable adults. The manager demonstrated a clear understanding of how to contact the safeguarding team, and when it was applicable to do so.

Is the service effective?

People living in the home had suitably detailed care plans which covered all aspects of their care and treatment. This included individual needs assessments, and people's preferences in regards to their care. We saw that people or their representatives had been involved in their care planning.

We found that people were supported by other health and social care professionals to provide them with additional care or treatment as needed.

We saw that the home provided people with a good range of foods to meet their dietary needs. Most dishes were home-made and included home-made soups and cakes every day. Fresh fruit and snacks were made readily available throughout the day. We saw that staff actively offered hot and cold drinks to people on a regular basis. People told us 'The food is lovely'; and 'The food is really good'.

We looked at staff training records and found that the home encouraged staff to take formal training such as Diplomas and Qualification Credit Framework (QCF) training. Most care staff had been trained or were studying for levels 2 or 3 in health and social care. Other staff had training relevant to their job roles such as catering or management qualifications. There was on-going training in required subjects to ensure staff were kept up to date.

Is the service caring?

People who were able to talk with us said that they were happy living in the home. People's comments included: 'I am looked after very well. The staff do a very good job, I feel cared for here'; and 'It's perfect here, the staff are very good.' Another person said 'There are always lots of activities here ' too much! So many to choose from.'

We spent a time of observation in one of the lounges for people with dementia, and we saw that staff spoke kindly to them and had caring attitudes. The staff noticed if people were agitated or wandering in a confused manner, and knew how to gently distract them. We saw that they did not rush people, but listened to them, and tried to show understanding and empathy with them.

We saw that some care plans showed that people preferred the same gender of staff when being supported with personal hygiene care. Staff were aware of this, and adhered to it.

People's care planning included life histories, so that the staff could appreciate people's previous lifestyles and hobbies, and be informed about their families and previous occupations. This enabled the staff to speak knowledgably to people with dementia, and help them to feel settled.

Is the service responsive?

The home employed a social assistant on each floor to arrange activities in line with the people's preferences on that floor. We saw that activity plans were in place for the week, but were flexible in accordance with people's wishes. For example, the day of our inspection was warm and sunny, and staff offered people the opportunity to sit outside in the afternoon for a tea party. Other people were taking part in gardening activities.

The staff encouraged people to take part in meal times or activities so as to prevent them from becoming socially isolated. However, they also respected people's decision to stay in their own rooms. Social assistants or care staff visited people who stayed in their own rooms, for individual conversation or activities during each day.

People were able to raise concerns or ask questions and were confident that they would be listened to and that suitable action would be taken to address their concerns. The manager had arranged for a recent telephone survey to take place with people's relatives. This provided the opportunity for family members to share their thoughts about the home, which was especially beneficial for people who had dementia.

The manager's office was in a prominent position adjacent to the reception area, and he had an open door policy. This meant that he was easily accessible to people when visiting their friends and relatives.

Is the service well-led?

The provider had systems in place for monitoring the home using weekly and monthly checks and audits. These included health and safety checks, medication audits, care plan audits, accident and incident reporting, pressure sore audits, and checks for unplanned hospital admissions. This enabled the manager to be informed about people's nursing and personal progress, and identified any trends in different areas of the home.

We observed that staff on each floor worked well together and interacted appropriately with people living in the home. Nursing and care staff were given different areas of responsibility, which enabled them to be more fully involved in the running of the home, and helped them to develop different competencies. We saw that staff were motivated to carry out their different roles. Several staff made comments such as 'I love working here', and 'This is the best place where I have worked.'

We saw that the manager was easily accessible to people living in the home, and staff and relatives. He took part in some of the nursing duties and staff training, which meant that staff were confident in his knowledge, abilities and leadership.

People we spoke with were happy with the care and support received. One person commented 'It is very pleasant living here, I have everything I need'. Another person told us 'The staff are approachable, I feel able to speak with all of the staff about my care and I feel safe when they support me'.

Relatives we spoke with were complimentary of all of the staff, one visitor told us that the staff were very caring and seemed competent and confident when supporting their relative.

During our inspection we saw that people were being spoken with and supported in a sensitive, respectful and professional manner.

The dinning areas on all three floors did not promote a homely environment or help aid orientation for people who had dementia. Tables did not contain condiments for people to be able to help themselves.

We saw that preparation was underway to install a tropical fish tank in the communal lounge on the top floor and staff told us that areas of the service were to be redecorated in bright colours to create a more interesting and stimulating environment for people living at the service.

People were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place for the storage and recording of medicines. There was insufficient guidance for staff on the use of some medicines and risk assessments were not in place where necessary.