This unannounced comprehensive inspection took place on the 8 and 9 August 2018.

At the last inspection on the 19 and 20 July 2017, the service was rated ‘Requires Improvement’. Three breaches of regulatory requirements were identified in relation to Regulation 9 [Person-centred care], Regulation 15 [Premises and equipment], and Regulation 18 [Staffing].

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions of ‘Safe’, ‘Effective’, ‘Caring’, ‘Responsive’ and ‘Well-Led’ to at least good. At this inspection, we found the service had improved in some areas but further work was needed to improve their rating which remains ‘Requires Improvement’.

Whilst we have acknowledged some areas of improvement, we found further work was needed to safeguard people from risks to their health, welfare and safety. For example, risks to people’s safety associated with inadequate staffing levels, safeguarding people from abuse and improper treatment, staff’s unsafe practice in supporting people with moving and handling, management of people’s medicines, catheter care and the monitoring of people at risk of inadequate food and fluid intake.

Whilst there was a number of management audits in place the overall governance systems did not always ensure the safety and quality of the service was maintained. The current arrangements were not as robust as they should be and improvements were required.

Great Horkesley Manor is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The care home accommodates up to 73 older people including people living with dementia in one adapted building. At the time of our inspection there were 56 people living at the service.

The service is located in the village of Great Horkesley, in a large purpose built, building situated within a residential area. The premises are set out over two floors and consists of three units, Wing, Willow and Chestnut a dementia care unit.

A registered manager was 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.

Staff demonstrated a good understanding of how to recognise and report abuse. However, people were not always safeguarded from abuse and improper treatment.

Poor moving and handling practices and the lack of social interaction from agency staff did not support a caring experience for people.

There continued to be insufficient numbers of staff to meet people’s assessed needs. Newly employed staff did not all receive induction training before they were left unsupervised. Their competency to move people safely had not been assessed. Training was not provided to skill all staff in areas such as meeting the needs of people with in-dwelling catheters, people at risk of choking, pressure ulcers and support of people living with dementia.

Staff were trained in medicines management and their competency was regularly assessed. However, audits did not always identify when people had not received their medicines as prescribed, including oral and creams and lotions.

The registered manager understood their role and responsibilities with regards to the Mental Capacity Act [2005]. Staff sought consent from people before providing support. People's capacity to make decisions had been assessed.

People spoke positively about the food and drinks they were provided with. People were given choice of what they ate and drank on a daily basis. However, people at risk of not having enough to eat and drink did not always rec

This inspection took place over two days on the 19 and 20 July 2017 and was unannounced.

Great Horkesley Manor provides accommodation and personal care support to 73 older people including some people living with dementia. During our inspection there were 59 people living at the service.

At our last inspection in July 2016 this service was rated as requires improvement as we found that the provider was not meeting the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found that risks to people’s health, welfare and safety had not always been effectively managed to prevent them from the risk of harm. The provider did not have effective quality and safety monitoring processes in place with actions required to ensure continuous improvement of the service. The service did not always protect people’s human rights and ensure that people were supported to exercise choice and control as to their preferred daily routines and how they chose to live their lives. Following that inspection the provider sent us an action plan to tell us what improvements they were going to make.

At this inspection we found action had been taken to improve the quality and safety for people in a number of areas. However, we also identified areas that further work was needed to increase the service's overall rating and ensure that people are provided with good quality, safe care at all times. For example, we found continued shortfalls in relation to care planning, staffing levels, staff training and induction of new employees and deployment of staff to meet people’s personal care needs. Further renovation and refurbishment of the environment was needed.

There was a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Staff received a variety of training relevant to their roles. The Deprivation of Liberty Safeguards (DoLS) were understood by staff. However, not all staff received induction training. We also found safe moving and handling training including refreshers were not always provided in a timely manner to ensure staff had the up to date skills and knowledge to keep people safe.

Staff demonstrated a good understanding of how to recognise and report any signs of neglect and abuse. Risks had been identified but were not always consistently managed.

There were systems in place to ensure the safe management of people’s medicines. People were supported to receive their medicines in a timely and safe manner.

People were supported to maintain good health and had access to appropriate services which ensured they received on-going healthcare support. However, improvement was required in the monitoring of people’s food and fluid input and output.

People's nutritional needs were assessed and professional advice and support was obtained for people when needed. People told us that the food was good, they were offered choice and that they were supported to have enough to eat and drink. Dietary needs and nutrition were being managed and advice sought from appropriate health professionals as needed. Health care needs were met with access to and support from external health care professionals.

Relationships between people and staff were positive. Staff were compassionate and promoted people’s dignity and treated them with respect. However, we found some people’s personal belongings had their room numbers recorded on them instead of their names. We recommended this system be reviewed to ensure that people’s rights to dignity be considered and respected fully.

Staff did not always access to people’s care plans and so were not always provided with the most up to date, consistent information as to people’s hea

Great Horkesley Manor provides accommodation and personal care for up to 73 older people. Some people have dementia related needs.

The inspection was completed on 7, 8 and 11 July 2016 and there were 49 people living at the service at the time.

A manager was in post but they were not registered with the Care Quality Commission. 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. This service has had managers in post, but there were times that they were absent for long periods and no one has been registered since April 2014.

The last inspection on 14 November 2014, found that the provider was not meeting the requirements of the Health and Social Care Act 2008 in relation to the management of complaints, the management of safeguarding concerns and the poor management of health care records. An action plan was provided to us by the provider on 29 May 2015. This told us of the steps they had taken and that the provider believed that they were already meeting the relevant legal requirements. During this inspection we looked to see if these improvements had been made.

We found that some improvements had been made in some areas but that there were other areas that gave us concern and were falling short of the respective regulations.

There was not always enough staff on duty to care for people when they wanted or needed it or to help keep people safe. Before our inspection, individual needs assessments had not been carried out to calculate the necessary staffing levels that people needed so that the necessary numbers of staff would be on duty. We have been informed that these were now being done.

Risks were not always managed in a way that kept people safe from preventable harm. Equipment was in use that were potential risks to people and no risks assessments had been done to determine what safeguards could be put in place to minimise risks to people. Fire risks were not recognised or attended to, there was no up to date fire risk assessment in place.

This service did not always protect people’s rights under the Mental Capacity Act. The Care Quality Commission (CQC) monitors the operation of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS) and are required to report on what we find. The MCA sets out what must be done to make sure the human rights of people who may lack mental capacity to make decisions are protected. The DoLS are a code of practice to supplement the main MCA code of practice. Where people lacked capacity to make day-to-day decisions about their care and support, we saw that decisions had been mostly made in their best interests, however there was an example where decisions had been made in relation to one person without making sure their legal rights were being protected.

People were not always given the choice of when to get up in the morning or when they could have their breakfast, sometimes they were got up earlier than they wanted and had to wait to have breakfast.

People’s care plans did not always reflect the current needs of the person. They had not been updated as their needs changed or their health had deteriorated.

Arrangements were in place to regularly assess and monitor the quality of the service provided.

However, the concerns and breaches to regulations that we have highlighted during our inspection were not identified or dealt with. This indicated that the service did not have an effective quality assurance monitoring process in place.

Effective arrangements were now in place to demonstrate that where safeguarding concerns were raised these had been responded to appropriately.

People enjoyed their meals and had enough to eat and drink to meet their needs and staff assist

Great Horkesley Manor provides accommodation and personal care for up to 73 older people. Some people have dementia related needs.

The inspection was completed on 14 November 2014 and there were 54 people living at the service at the time.

A manager was in post but they were not registered with the Care Quality Commission. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The last inspection on 28 May 2014 found that the provider was not meeting the requirements of the law in relation to the care and welfare of people who used the service, quality assurance, the management of medicines and staffing. An action plan was provided to us by the provider on 14 July 2014. This told us of the steps taken and the dates the provider said they would meet the relevant legal requirements. During this inspection we looked to see if these improvements had been made.

People told us that if they had any concerns they would discuss these with staff on duty. Although people told us that they were confident that their complaints or concerns were listened to, taken seriously and acted upon, complaints had not been fully investigated.

Effective arrangements were not in place to demonstrate that where safeguarding concerns were raised these had been responded to appropriately.

People and their relatives told us the service was a safe place to live. Staff were able to demonstrate a good understanding and knowledge of people’s specific support needs, so as to ensure their and other’s safety.

Staffing levels were appropriate to meet the needs of people who used the service.

The management of medicines was suitable and people received their medication safely.

People’s healthcare needs were well managed and we found that the service engaged proactively with health and social care professionals.

The Care Quality Commission (CQC) monitors the operation of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS) and are required to report on what we find. The MCA sets out what must be done to make sure the human rights of people who may lack mental capacity to make decisions are protected. The DoLS are a code of practice to supplement the main MCA code of practice. Where people lacked capacity to make day-to-day decisions about their care and support, we saw that decisions had been made in their best interests. The registered manager was aware of recent changes to the law regarding the Deprivation of Liberty Safeguards (DoLS) and at the time of the inspection they were working with the local authority to make sure people’s legal rights were being protected.

People’s care plans were reflective of their care needs and risks to people’s health and wellbeing were recorded.

Staff felt supported and valued. Staff received regular training opportunities. Staff received a robust induction, supervision and appraisal.

Comments about the quality of the meals provided were variable across the service. The dining experience for people was positive and people received appropriate support with their meals.

We found that an effective system was in place to regularly assess and monitor the quality of the service provided. The manager was able to demonstrate how they measured and analysed the care provided to people who used the service and how this ensured that the service was operating safely.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 in relation to safeguarding and complaints management. You can see what action we told the provider to take at the back of the full version of the report.

We carried out our inspection in response to information of concern received from the local authority and others about poor staffing levels and the care and support provided to people who used the service. As part of this inspection we spoke with six people who used the service, five relatives, six care staff, two visitors and a member of the management team. We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

This is the summary of what we found:

Is the service safe?

Staff received training in safeguarding vulnerable adults from abuse and the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). The service had appropriate policies and procedures in place in relation to the MCA and DoLS although currently no applications had been submitted.

The entrance of the building was secure with a recently implemented keycode system in place.

We found medicines were stored safely for the protection of people who used the service. People were not provided with their medication in a safe manner. We were not assured that appropriate and effective monitoring arrangements were in place to identify and resolve medication errors promptly.

We found that there were not always sufficient numbers of staff on duty to safely meet the needs of people throughout the day and night. There was a high percentage of agency staff working in the service. People we spoke with told us staff did not always respond to their call bells promptly. One person we spoke with told us, “I feel safe here but I do not think there is enough staff at night. Staff tell me they have lots to do and there is not enough of them.”

Is the service effective?

People’s health and care needs were assessed in consultation with either the person themselves, relatives or their advocate. People had a plan of care in place that reflected their healthcare needs in conjunction with support from external professionals, where required.

Is the service caring?

The interactions we observed by staff were kind and we found the majority of staff responded appropriately to people’s requests and needs. We spoke with relatives, one told us, “The staff do their best but there has not been enough of them. Things are improving but the place is full of agency staff.” Another relative told us, “The staff do their best. I have no concerns about their care of my (relative).”

Is it responsive?

People's care records showed that where concerns about an individual's wellbeing had been identified, staff had taken appropriate action that ensured people were provided with the support they needed. This included seeking support and guidance from health care professionals, including a doctor and community nurse.

People, who used the service and their relatives, told us that they considered staff were not always available when they needed them as staff did not always respond to their call bells promptly. One person told us, “They are fairly quick during the day but at night they are not very quick, I think they are tired at night.”

People who used the service and their relatives involved in the service had completed monthly satisfaction surveys. Issues raised had been addressed with action plans implemented.

People were involved in participating in a range of activities both within the service and were also offered regular visits from outside entertainers. However, we found that activities provided for people living with a dementia were not always appropriate given some people’s complex needs.

Is the service well led?

The registered manager was absent from the service and the service was currently being managed by an Interim manager.

The provider had quality assurance systems in place to regularly assess and monitor how the service was managed and to monitor the quality of the service. There was evidence that these systems had identified a number of shortfalls and some improvements had been made which would improve protection for people from inadequate standards of care and to identify any areas of non-compliance. However, we were not assured that the systems for identifying shortfalls, for example in supplying sufficient numbers of staff were always effective.

On the day of inspection there were 57 people living at Great Horkesley Manor.

We spoke with seven people who lived at the home. One person said to us, "I've got no complaints or concerns; the staff are very kind." Another person commented, "I like the lovely views from my room." No one we spoke with raised any concerns with us.

The registered provider had undergone a complete change of management two months prior to the inspection. Since then the new management had implemented a range of quality monitoring systems to ensure that care was being delivered appropriately by staff in line with individual care plans, and that the service was continuously challenged to improve.

We saw that people's support plans and risk assessments reflected their needs and were up to date. Staff we spoke with were aware of the contents of the care plans, which enabled them to deliver safe care in line with those plans. The provider had systems in place that ensured the safe receipt, storage, administration and recording of medicines. Staff recruitment systems were robust.

The home was warm, clean and was personalised to the people who lived there. The accommodation was adapted to meet the needs of the people living there, was suited to caring for people with limited mobility and the provider had a suitable maintenance and renovation plan in place for the future.

We spoke with eight people using the service and two relatives and observed the care provided. One person told us, “The staff are very good here and look after me well.” They had recently had their hair and nails done and were smartly dressed. A family member told us, “My relative is always smartly presented and I feel they are safe at the home.” One person said, “I do not feel that the activities here are suited to my needs.” However this was being addressed by the activities coordinator. One relative told us that their family member was initially unsettled when moving to the home, but was now more secure and benefitted from the routine. They said, “The home is open and inclusive and they keep me informed about my relatives care.”

We spoke with staff and looked at staffing records. Staff were supported and appropriately trained to meet people’s needs. Staff were employed in sufficient numbers to meet people's needs. The service had safe systems for staff recruitment, which meant that people were supported by staff who had been properly vetted.

Standards of cleanliness and maintenance in the home were high which meant the premises were safe and comfortable.

Care records examined clearly described how to meet people’s needs and we saw that people’s needs were being met appropriately. We were concerned about the lack of social activities taking place in the dementia care unit which staff told us were difficult to provide due to their dependency levels.