Harbour Care Centre

The home has 108 beds over four floors, however at the time of the inspection there were only two floors operational. 27 people were living in the home. The home had recently registered for nursing but had not yet taken people with nursing needs into the home as they were in the process of establishing the necessary staff team.

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

People experienced good care, delivered by staff who were kind and caring. Feedback from people was positive and our observations supported this. People were treated with dignity and respect and their privacy maintained.

People were safe because there were sufficient staff in place to meet their needs. The registered manager told us they were in a position to increase occupancy in the home but would only do this in a safe, carefully managed way. People received support with their medicines when required; these were stored and administered safely. The home was clean and there was a team of staff in place to support good infection control practices.

Staff received training and supervision to enable them to work effectively and with the necessary skills. People received good support nutritionally; their needs were monitored and assessed regularly and support from the GP was sought when required.

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.

Care was planned in a person centred way, with people views, needs and wishes incorporated in to their care plans. People’s end of life wishes, and plans were discussed with them. There was a programme of activities in place to support people in staying socially connected. This included making links with the local community.

The service was well led. Improvements had been made and sustained over a period of time and there was a strong person centred culture within the service. There were systems in place to monitor safety and quality.

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 (5 April 2019). There were no breaches of regulation at this time, however due to the previous history of the home we needed to observe a sustained period of improvement. At this inspection we found improvement had been sustained and built upon and the service was rated good.

Why we inspected

This inspection was carried out to follow up on the requires improvement rating the service received at our last 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 changed from required improvement to good based on the findings of this inspection.

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

Harbour Residential is a residential care home for up to 108 people that was providing personal care to 12 people aged 65 and over at the time of the inspection.Since the last inspection the service has changed its name from Haven Lodge Care Centre to Harbour Residential and the provider registration has remained the same with CQC

People’s experience of using this service:

At our previous inspection we rated the service Inadequate. The failings were mostly regarding the provision of nursing care at the home. The provider has now cancelled their registration for nursing care and is no longer delivering this regulated activity. The service has been in Special Measures and has not achieved a rating higher than Requires Improvement since we began rating services in 2016.

We have rated this service as Requires Improvement as the provider needs to demonstrate that the improvements we found can be sustained with higher occupancy. At the previous inspection in September 2018 we found seven breaches of the Health and Social Care Act (2008). At this inspection we found the provider was no longer in breach of regulations.

People told us they were happy at the service. They felt safe and well-cared for by kind and caring staff. People’s relatives confirmed they were confident their loved ones received safe and kind care.

People were complimentary about the food. They had a choice of meals and were always able to have an alternative. Staff made sure people had enough to drink and received any support necessary to eat their meals. The kitchen staff were aware of any special dietary needs.

The environment was bright, well-maintained and clean throughout. There was a range of activities available including visits from a mother and toddler group which took place during our inspection.

Care was delivered by staff who were trained and supervised. Staff had undergone recruitment checks before being employed by the service. Staff morale was good and we observed staff interacting with people in a way they preferred.

People’s care needs were assessed and their care delivered in the way they preferred. Any risks to people were assessed and plans put in place to reduce risks. People’s emotional and social needs were included in their plans of care. Relatives were involved in planning and reviews of people’s care and could discuss any change in needs. They were informed of any incidents such as falls. People’s protected characteristics under the Equalities Act 2010 were not always considered in detail in people’s care plans. We have made a recommendation about this.

The provider sought feedback from people and their families. A satisfaction survey had recently been carried out which scored highly. The service had received a high number of compliments; many relatives expressed how satisfied they were with the care their loved ones received.

The registered manager demonstrated good leadership and staff morale was high. Staff told us they were well-supported and confident they would be listened to if they raised any concerns or had ideas for improving the service. The provider operated a clear governance system to identify and rectify any shortfalls.

Rating at last inspection: Inadequate (September 2018)

Why we inspected: This was a planned inspection based on the previous rating. The service’s rating had improved to Requires Improvement from Inadequate.

Follow up: We will continue to monitor the service through the information we receive. We will inspect in line with our inspection programme or sooner if required.

At our comprehensive inspection of this service in November 2016 seven breaches of legal requirements were found. The provider was not following the Mental Capacity Act 2005, people were not having their care provided in a dignified or respectful way. People were receiving unsafe care and treatment and were at risk due to inadequate care relating to their nutrition and hydration. The provider had inadequate systems in place that identified shortfalls and records were incomplete. Staff were not receiving training, supervisions or had the skills and knowledge to support people within the service. There were also inadequate checks undertaken on new staff prior to them starting employment at the service.

Following this inspection, we placed the provider on notice of urgent action and we put the service into special measures. This is when the provider is responsible for the care it provides and for improving quality and safety in response to our judgements and ratings. When a service is in special measures we expect the provider to seek out appropriate support to improve the service from its own resources and from other relevant organisations. The provider also wrote to us to say what they would do to meet legal requirements in relation to these breaches.

The service was inspected in February 2017. After this inspection we used our enforcement powers and served a Warning notice on the provider, in relation to Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in April 2017, as the provider's quality assurance systems were not in place or effective at identifying shortfalls relating to infection control, personal evacuation plans and medicines management. Some audits had been undertaken during and following our inspection those shortfalls were yet to be actioned This is a formal notice which confirmed the provider had to meet one legal requirement by May 2017 .

We undertook a comprehensive inspection in July 2017. This was to follow up our warning notice issued and previous breaches of legal requirements. At this inspection whilst there were some improvements there were still concerns relating to previous breaches including records that were inaccurate and incomplete and shortfalls in staffing numbers, staff receiving training, supervision and a regular appraisal of their performance yearly appraisal. The service was rated as Requires Improvement.

We undertook an unannounced focused inspection of Haven Lodge Care Centre on 22 February 2018. This inspection was carried out to check that improvements to meet legal requirements planned by the provider after our comprehensive inspection had been made. We had received information that the management arrangements in the service were not consistent. This focused inspection looked at the breach of regulations 12, Safe Care and Treatment, 17, Good Governance and 18 , Staffing. At this inspection, we found the provider had taken action to comply with some of the legal requirements. However, further improvements were still required regarding the recording of medicines, support plans and effectiveness of quality assurance systems. We found continued breaches of Regulations 12 and 17.

You can read the reports from our last inspections, by selecting the 'All reports' link for Haven Lodge Care Centre, on our website at www.cqc.org.uk. The service remains rated as requires improvement.

Haven Lodge is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement . The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. Haven Lodge Care Centre is a registered nursing home and can accommodate 106 people. At the time of the inspection there were 27 people living at the service. The accommodation at the time of the inspection was arranged over two floors. The first floor is Willow and the second Sycamore. Each floor could have up to 27 people living on them. The third and fourth floors were not being used at the time of the inspection. Both Willow and Sycamore floors had a communal lounge, dining area, bathrooms and toilets.

Since the last inspection in February 2018 the previous registered manager had left the service. At the time of our inspection the manager was not registered with CQC. The manager had been in post for two months, and was the third manager in four months. 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 last inspection in February 2018, the service was rated, 'Requires Improvement'. We found breaches in Regulation 12 and Regulation 17. Some protocols for the use of ‘when required’ (PRN) medicines were missing in care files. Quality checks on the service were not robust enough and lessons learnt not passed on to staff to improve the service. We asked the provider to take action to make improvements to medicines and quality monitoring. At this inspection we found there had been no improvements and the issues remained regarding the review of these and in the management of quality checks. This is the second time the service has been rated 'Inadequate’. We found there remained breaches of Regulation 17 and 12. In addition we found four other breaches.

Medicines were not managed consistently safely. Where people received their medicines without their knowledge (covertly) the provider had not followed best practice guidelines.

The issues associated with Regulation 11 we had found in our last comprehensive inspection in July 2017, had been addressed but a new breach of Regulation 9 (Person centred care) of the Health and Social Care Act was identified with regards to the ongoing review of people's care to ensure it remained appropriate to their needs and preferences.

We looked at six care plans and found some improvements to the information relating to people's needs and wishes had been made but other information was poor. Some of the information relating to people's level of risk was contradictory, some of the risk management advice stated was inadequate and some people's risk management plans were not followed. This meant that there was a risk that people's health and welfare were not being managed properly.

Improvements were needed to the way people's ability to make decisions about their care had been assessed and the way people's legal consent was obtained in line with the Mental Capacity Act 2005.

People had access to a limited range of social or recreational activities in support of their emotional well-being.

People and the relatives told us that there were not enough staff on duty to meet their needs.

Staff supervisions and staff appraisals were not up to date. Nursing staff had not received clinical supervision for some time.

The provider had audits in place to check the quality of the service but these were ineffective. Improvements to the care planning and the delivery of care identified at the last inspection had not been sustained through good management and some aspects of service delivery had declined in terms of quality and safety.

The audit and governance systems in place failed to pick up and address the issues found at this inspection.

Managerial and provider oversight was insufficient and by consequence the ability to mitigate risks to the health, safety and welfare of people who lived at the home was seriously compromised. This service was not well-led. The provider had failed to inform us about one incidents.

People on Willow floor told us that staff were kind, however on Sycamore floor, staff found it difficult to care for people as they would like to due to lack of staff.

Staff had been recruited safely.

Staff interacted with people well and were kind and considerate in most of their support interactions.

People who required special diets were provided with the diet they needed and people's food and drink charts were completed appropriately.

The environment was clean and safe but there was a noticeable odour on Willow floor. The home's gas, electric and moving and handling equipment had all been certified as safe to use .

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.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

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 or cancel the

We undertook an unannounced focused inspection of Haven Lodge Care Centre on 22 February 2018. This inspection was carried out to check that improvements to meet legal requirements planned by the provider after our comprehensive inspection had been made. This focused inspection looked at the breach of regulations 17 and 18. This report only covers our findings in relation to this area. You can read the report from our last comprehensive inspection by selecting the, 'All reports' link for ‘Haven Lodge Care Centre’ on our website at www.cqc.org.uk

No risks, concerns or significant improvement were identified in the remaining Key Questions through our ongoing monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

Haven lodge provides accommodation and personal/nursing care for up to 108 people.

At the time of the inspection there were 24 people living at the home. The accommodation at the time of the inspection was arranged over two floors. The first floor is Willow unit and the second floor is Sycamore unit. Each floor could have up to 27 people living on them. The third and fourth floors were not being used at the time of the inspection. Both Willow and Sycamore units had a communal lounge, dining area, bathrooms and toilets.

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 this inspection, we found the provider had taken action to comply with some of the legal requirements. However, further improvements were still required in regards to the recording of medicines, support plans and effectiveness of quality assurance systems.

People's care plans did not always contain support plans relating to their individual care needs including catheter care or Parkinson's disease.

People did not always have accurate records that confirmed if they had been administered their medicines or had protocols for medicines that were given as required.

Whilst the provider had a system in place to monitor the quality and safety of the service. It was still not effective enough to identify shortfalls found during this inspection.

People who required medical supplements were given medicines belonging to other people.

We found medicines belonging to people who were no longer living at the service.

People’s medicines were stored accurately and creams administered to people. Where people were at risk of dehydration; records relating to the amount people had drunk had improved.

People were now supported by staff who had received training and an annual appraisal.

People were supported by sufficient numbers of staff.

People were now receiving correct support relating to their skin care due to accurate handover sheets and staff were all familiar with people's care needs.

People's air mattresses were now accurately set when they were at risk of their skin developing pressure sores. When daily checks were being undertaken these identified mattresses that had been incorrectly set due to accurate records of what the mattress should be set to.

At the time of the inspection there were 42 people living at the home. The accommodation at the time of the inspection was arranged over two floors. The first floor is Willow unit and the second floor is Sycamore unit. Each unit could have up to 27 people. The third and fourth floors were not being used at the time of the inspection. Both Willow and Sycamore units had a communal lounge, dining area, bathrooms and toilets.

At our last comprehensive inspection of this service on 10, 11, 14 November 2016. Seven breaches of legal requirements was found as the provider was not following the Mental Capacity Act 2005, people were not having their care provided in a dignified or respectful way. People were receiving unsafe care and treatment and were at risk due to inadequate care relating to their nutrition and hydration. The provider had inadequate systems in place that identified shortfalls and records were incomplete. Staff were not receiving training, supervisions or had the skills and knowledge to support people within the home. There was also inadequate checks undertaken on new staff prior to them starting within the home.

Following this inspection we placed the provider on notice of urgent action and we placed the service into special measures. This is when the provider is responsible for the care it provides and for improving quality and safety in response to our judgements and ratings. When a service is in special measures we expect the provider to seek out appropriate support to improve the service from its own resources and from other relevant organisations. The provider also wrote to us to say what they would do to meet legal requirements in relation to these breaches.

The home was last inspected on the 23 and 24th February 2017. At the last focussed inspection we found breaches of legal requirements. After this inspection we used our enforcement powers and served a Warning notice on the provider on the 4 April 2017. This is a formal notice which confirmed the provider had to meet one legal requirement by the 25 May 2017.

We undertook this unannounced comprehensive inspection on the 17 and 18 July 2017. This was to follow up our warning notice issued and previous breaches of legal requirements. At this inspection whilst there were improvements there were still concerns relating to previous breaches including records that were inaccurate and incomplete and shortfalls in staffing numbers, staff receiving training and a yearly appraisal.

People could be at risk of not receiving support relating to their skin care due to inaccurate handover sheets and staff being unfamiliar with people’s care needs.

People’s air mattresses were not always accurately set when they were at risk of their skin developing pressure sores. When daily checks were being undertaken these did not identify mattresses had been incorrectly set due to no record of what the mattress should be set to.

Medicines were not always stored accurately and creams administered to people did not always have accurate records that confirmed if people had been administered their medicines. Where people were at risk of dehydration; records relating to the amount people had drank needed improving. People’s care plans did not always contain support plans relating to their individual care needs including catheter care, Parkinson’s and bowel care. There was a lack of robust systems and checks in place that identified shortfalls found during this inspection.

People were not always supported by staff who had received training or an annual appraisal. People, staff and relatives all felt the home did not have sufficient staffing levels. At the time of the inspection the home had a number of vacant hours and there was a 14.34% use of agency. The registered manager and provider were trying to reduce the amount of agency being used. They felt it was about getting the right staff in with the right skills and attitude.

People were supported by staff who had checks completed on their suitability to work with vulnerable people prior to starting their employment.

People received food that looked appetising, nicely presented and meal times were relaxed and unhurried. People had access to snacks and drinks throughout the day and people who were at risk of losing weight had gained weight.

Referrals were made to health care professionals when required. People’s care plans had consent forms for those who lacked capacity. Care plans had been signed by the person or where people lacked capacity another responsible person such as family member had given their consent.

People received care that was respectful and kind and they felt staff treated them with dignity and respect. People were supported to maintain relations that were important to them.

People could participate in activities of their choice, including exercises, music, aromatherapy, signing, physiotherapy and walks into the local community.

People had a personal evacuation plan in place that confirmed what support they would require in case of an emergency.

People and relatives felt able to complain should they need to.

We have identified two 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 the full version of the report.

Haven Lodge provides accommodation and personal/nursing care for up to 108 people.

At the time of the inspection there were 41 people living at the home. The accommodation at the time of the inspection was arranged over two floors. The first floor is Willow unit and the second floor is Sycamore unit. The third and fourth floor were not being used at the time of the inspection.

Both Willow and Sycamore units had a communal lounge, dining area, bathrooms and toilets.

At the time of this inspection the home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ¿¿‘registered persons’. Registered persons have legal responsibility for meeting the requirements in ¿the Health and Social Care Act 2008 and associated Regulations about how the service is run. ¿

We carried out a comprehensive inspection of this service on 10, 11 and 14 November 2016.

Breaches of legal requirements were found as people were not receiving safe care and treatment in relating to their nutritional needs, skin care and medicines. There were unsafe recruitment practices in place as staff were not receiving checks prior to starting their employment. There were insufficient numbers of staff to keep people safe and meet their needs. We also found ineffective quality assurance systems were in place to make sure ¿any areas for improvement were identified and addressed.¿

After the comprehensive inspection, we placed the provider on notice of urgent action. This was because people were receiving unsafe and inadequate care. The management of the home was inadequate along with the quality assurance systems in place. The provider provided an action plan of how they were going to address the significant risks found during that inspection.

We undertook this focused inspection to check the service was now safe and well-led. We also checked to ensure the provider was meeting their legal requirement. This ¿report only covers our findings in relation to these requirements. You can read the report from our ¿last comprehensive inspection, by selecting the 'all reports' link for on our website at ¿www.cqc.org.uk

We found some actions had been taken to improve how safe and well-led the service was but improvements were still required to meet legal requirements.

The management of medicines was not always safe due to stock no longer required being held by the service. Record keeping was poor, medicines were not dated when they were opened and fridge temperatures were not being recorded.

Personal evacuations plans were not always in place and contained old and out of date information.

People at times had to wait for support and assistance from staff during meals times.

Quality assurance systems were not always in place and effective as we found shortfalls relating to personal evacuation plans and medicines management. There was no system for checking the building, health and safety, fire safety and the cleaning of equipment such as hoists. Some audits were sent following the inspection; these identified actions required. We will review the actions completed and the effectiveness of these new audits at our next inspection.

People were receiving improved care relating to their nutrition and hydration and people were putting weight on.

People were being supported with repositioning when at risk of developing pressure related although records required some improvements.

People were supported by staff who had checks undertaken prior to working in the service. Improvements had been made to reduce the use of agency staff and there were some weeks when the provider had not used agency staff.

People and relatives felt improvements had been made following the recruitment of the registered manager and new staff. Comments from people included, “The carers are very kind they treat us just like family”, “Nothing is too much trouble for them” and “Things have improved remarkably since the arrival of the new manager.” Relative's told us, “The morale of the carers has improved no end, and as a result the care is better now” and “I feel [Name] is safe as there are staff around to help them when required”.

Feedback from staff and relatives was that the registered manager was approachable and accessible.

Meetings were being held with relatives and staff and minutes of these meetings confirmed they were an opportunity to raise questions with the registered manager.

The provider had not met all the legal requirements.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

At the last comprehensive inspection this provider was placed into special measures by CQC. This inspection found that there was not enough improvement to take the provider out of special measures.

CQC is now considering the appropriate regulatory response to resolve the problems we found.

During our inspection, we found that not only had there been no improvements made, there were more concerns and many of those were of a higher risk. For example in relation to person centred care and staffing we found that there had been further deterioration and the risks posed to people had increased. We also found further breaches of the regulations in relation to nutrition and hydration, and dignity and respect.

The home still did not have a manager registered with the Care Quality Commission. The home had been without a registered manager since 2015. Two managers had been in post since that time and one had been in the process of registering with the commission but had left the service in August. Since August 2016, the provider had placed two support managers and a support deputy manager from their other homes, in the service to assist staff and run Haven Lodge until a new manager could be recruited.

The service is required to have a registered manager and was therefore in breach of this regulation. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are 'registered persons'. Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run. We had been made aware of a number of people who had left the service and a number of staff currently within the home were working their notice to leave, this included a senior carer, unit manager and a number of care staff.

This inspection found that people's safety was being compromised in a number of areas. Care plans did not reflect people’s care needs and care delivery was not person specific or holistic. We found that care plans for people with specific health problems such as diabetes, pressure areas, and wounds were not up to date and did not have sufficient guidance in place for staff to deliver safe treatment. The delivery of care suited staff routine rather than individual choice.

During this inspection, we followed up on information of concern we had received regarding people's food and fluid intake. We found that people were not being supported or prompted to have sufficient fluid or nutrition. We reviewed the information and support available to ensure people received enough nutrition and hydration. We found that records kept to monitor people's intake of food and fluids were poorly completed, inaccurate and did not outline why people were being monitored which meant people were placed at risk.

We looked at risk assessments and saw there was little up to date comprehensive information to identify what the risks were to people. How staff protected people from risks did not always reflect recent advice from other health care providers. People were not always supported in line with their care plans. We therefore found the home was in breach of the regulation in relation to safeguarding and improper treatment.

At the last inspection in December 2015, we found there were not enough qualified skilled or experienced staff to meet the needs of the people using the service. We checked and found that the provider had still not ensured there were enough suitably trained or qualified staff deployed to meet the needs of people who used the service. We found the home was still in breach of the regulation relating to staffing. The lack of suitably qualified and experienced staff impacted on the care delivery and staff were unable to deliver care in a safe manner. Shortcuts in care delivery were identified particularly in respect of personal care.

People and visitors we spoke with were complimentary about the caring nature of some of the staff. However, the constant changes to staff, use of agency staff and staff leaving had impacted on how the home was run. Many people were supported with little verbal interaction, and many spent time isolated in their rooms. Staff told us they thought that communication systems needed to be improved and they required more support to deliver good care. They felt that the lack of permanent staff and high staff turnover had raised issues. Their comments included, "Staff leaving and not showing up for work has been really difficult, we don't always know who is supposed to be on duty."

Due to the level of risk, we found during the inspection, we made the local authority and Health Service aware of the concerns we had which included the staffing levels at the home. The Council liaised with the provider and ensured there was an extra nurse available on shift to support the home over the weekend. We also asked the provider to send us an emergency action plan outlining what they were doing to safeguard the people at the home along with some additional information.

At the last inspection, we found there was, 'no system in place to assess people's capacity to consent to care and consideration was not given to the principles of the Mental Capacity Act 2005.' At this inspection, we saw that the provider had begun the process of assessing the capacity of people who were most at risk but found evidence of people receiving care and treatment without their consent. This meant the provider was still in breach of this regulation. Mental capacity assessments and best interest decisions were not completed in line with legal requirements.

Staff were not always following the principles of the MCA. There were restrictions imposed on people that did not consider their ability to make individual decisions for themselves, as required under the MCA Code of Practice. There was confusion over whether deprivation of liberty safeguards (DoLS) were in place for people. The management list of DoLS was not up to date or accurate.

At the last inspection in December 2015, we found breaches in relation to good governance. This was because, there was a lack of leadership and management within the home which meant quality audits were not being completed and the quality of care being delivered was compromised as a result. At this inspection we found no improvement because systems already established were not being used to monitor or manage the quality of service provided either at service or provider level. Quality assurance systems were in place but had not identified shortfalls in care delivery and record keeping. We could not be assured that accidents and incidents were consistently investigated with effective action planning to prevent a re-occurrence. This was a continued breach of this regulation.

Though people spoke highly of the food provided by the kitchen at Haven Lodge, we found meal times were task orientated activities that did not promote people's independence or enjoyment.

Care plans lacked sufficient information on people's likes and dislikes. Information in respect of people's lifestyle choices was not readily available for staff. The lack of meaningful activities impacted negatively on people's well-being. At the last inspection we saw examples of staff interacting with people in positive and caring ways but it was clear that at times they were simply too busy and some interactions were rushed or missed. We found the same thing occurred at this inspection, which meant some people received poor care and treatment.

We also found that training had not been delivered where identified and staff had not received regular supervision and had not had an appraisal on a yearly basis.

We found a number of concerns in relation to medicine management. These included people not receiving medicines in line with their prescription, missing pain patches, medicines of people who were no longer living in the home were still accessible to staff and staff were not keeping a record of when, where or why they were administering creams. We also found that those medicines that required more security were not stored safely or securely.

The recruitment system was not always safe or effective. The staff files we looked at contained a completed application form, listing work history as well as skills and previous qualifications and all nurses had up to date registrations with the nursing midwifery council (NMC), however, we found and we were told by the support manager and deputy manager that they did not have copies of Disclosure and Barring certificates or a record of the certificate numbers for 10 staff working in the service. This meant the provider did not ensure that persons employed were of good character and had satisfactory checks in place. This placed people’s safety and wellbeing at risk.

People had access to appropriate healthcare professionals. Staff told us how they would contact the GP if they had concerns about people's health.

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.

Services placed in special measures will be inspected again within six months. The service will be kept under review and if needed could be escalated to urgent enforcement action. Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

The focus of the inspection was to answer five questions: Is the service safe, effective, caring, responsive, and well-led.

Is the service safe?

Staff told us they had not received all necessary training although we were told moving and handling training had been arranged for 18 September 2014. Staff's understanding of safeguarding vulnerable adults was variable. Some staff told us they would report concerns immediately to a senior staff member. Safeguarding policies, procedures and local guidelines where not on display for staff to follow if necessary.

We saw some staff had a good rapport and interacted well with the people living in the home. However, we saw some staff were not always able to manage situations when people expressed their feeling of anxiety and frustration. Staff and relatives told us the home was often short staffed and there was a heavy reliance on agency staff.

People were not protected from the risk of infection. Systems for safe food handling were not in place. The kitchen and areas of the home were dirty. The staff did not have appropriate facilities for hand hygiene and we saw staff did not protect people from the risk of cross infection. We have warned the provider that they must comply with the requirements of the law in relation to Regulation 12.

Is the service effective?

People were not cared for by staff who had received training relevant to their role. Staff were not properly supervised or appraised. One new member of staff told us they had received a one day induction which included fire training. They confirmed this had been a 'walk through' and they had not received formal training. One staff member told us they had received supervision prior to the registered manager leaving but they had not received anything further. Other staff told us they had not had an appraisal or supervision since starting employment at the home.

People's health and care needs were assessed at the time of their admission but we found people were not involved in the development or review of their care plans. The records did not identify external health professional's involvement.

People were at risk from receiving care and treatment that was inappropriate or unsafe by unskilled members of staff. We have warned the provider that they must comply with the requirements of the law in relation to Regulation 23.

Is the service caring?

We spoke with people living with dementia on the third floor and they told us their individual bedrooms were 'not bad' and staff were 'very willing' and 'helpful.' Two of the people said they did not see 'staff too often' and were 'left on our own for quite some time but they were used to it.'

We spoke with people on the general nursing floor and they told us they were able to make choices about times they got up and went to bed but their privacy and dignity was not always respected. During our visit, we observed there was a relaxed atmosphere with people choosing where they wished to spend their time. We observed some staff treating people with kindness and patience.

We saw people freely expressing what they wanted to do during the day, and they were supported by reassuring staff. People told us staff were "as good as gold" and they had 'no axe to grind.'

Relatives said the staff were good but there was a heavy reliance on agency staff. They said consistency was not maintained because agency staff did not know the needs of people.

We spoke with staff, and observed the interactions they had with people. We found some staff spoke kindly and demonstrated an understanding of people's needs. However, we saw staff on occasions did not follow the care plan for example a firm approach was used when a calm approach was advised. This meant staff were not following the guidance given to them. We asked staff if they enjoyed working at the home. Staff's responses were variable. One said they enjoyed working at the home and another said there was 'nothing' they liked about working at the home.

Is the service responsive?

People had their needs assessed and had been allocated a key worker. However, we found no evidence within the records of the key worker's involvement with people. A key worker is a designated member of care staff with specific responsibility for a named person who lives in the home. Care plans did not guide staff on how to consistently meet the needs of people.

Staff told us that some people had difficulty communicating although they understood what was said. Staff told us people were able to respond through various means, which included the use of signs and gestures.

Is the service well led?

We saw no evidence that people were asked for their feedback about how the home was run. People told us they liked their home

The day to day running of the home was delegated to a manager but this manager was not registered with the Care Quality Commission as required by legislation.

There were no systems in place to manage and monitor risks. For example, infection control and staff appraisals, supervision and training. We have warned the provider that they must comply with the requirements of the law in relation to Regulation 12 and Regulation 23.

The provider was required to provide a report that stated what action they were going to take to achieve compliance with this essential standard. The provider submitted an action plan on 10 June 2013. The purpose of the inspection was to check that the necessary improvements had been made to ensure compliance with the essential standard.

We found that the provider had introduced a system which ensured that staff members were supported to enable them to deliver care and treatment to an appropriate standard.

Not all people were able to verbally tell us about the care and support they received. Therefore we observed how staff interacted and supported people, to enable us to make a judgement on how their needs were being met.

Overall comments were positive from people who were able to communicate verbally. Comments included; "staff always ask me how I want things done; we all sail along' and 'they always get a drink if you ask for it; and the food is very good and plenty of it.'

We viewed one care plan from each floor. The planning was centred on the individual and considered all aspects of their individual circumstances. The care plans were detailed and specific to the individual's needs and preferences.

Staff we spoke with were knowledgeable about the people they supported. The majority of staff had received training appropriate to their roles. We found that there was not an adequate support structure in place for staff supervisions and appraisals.

We found that the provider had systems in place to deal with complaints, including providing people who used the service and their relatives with information about that system.

Records showed that people living in the home had an opportunity to discuss their care and family or representatives were consulted where this was needed for example where a person had dementia and was unable to express their view.

People we spoke with told us that they were happy with the care they received and that staff were helpful and kind. One person told us, "I always get the care I need". Records showed detailed information about the health and social care needs of the individual.

We found that the provider had taken reasonable steps to protect people using the service from abuse. We found that staff had received the necessary training so that they had the knowledge and skills to respond professionally to any concerns about possible abuse. We found that staff were trained to provide appropriate care and that they received regular supervision. People told us that staff were caring and supportive with one person telling us that staff were able to give them the care and support they needed.