We carried out a comprehensive inspection of Halvergate House on 16 and 17 January 2016. We found breaches of three regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 during that inspection. These breaches were in relation to people’s nutrition and hydration, treating people with dignity and respect and good governance of the service.

We undertook this unannounced comprehensive inspection on 17 and 18 October 2017 to look at all aspects of the service and to check that the provider had made improvements and that the service now met legal requirements. At this inspection, we found improvements had been made in the required areas and the provider was no longer in breach of the regulations.

You can read the report for previous inspections, by selecting the 'All reports' link for ‘Halvergate House’ on our website at www.cqc.org.uk

Halvergate House is registered to provide accommodation for up to 50 people who require nursing and personal care, some of whom may be living with dementia. At the time of our inspection, 38 people were living at the service.

There was a registered manager in post. 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.

Staff knew how to keep people safe from abuse. Staff were confident that if they had any concerns they would be addressed quickly by the registered manager. Risks to people had been assessed and regularly reviewed. Actions had been taken to mitigate these where necessary. Checks had been made on the environment to ensure the service was safe. Equipment to support people with their mobility, such as hoists had been checked to ensure people were safe.

There were enough staff to ensure people were safe and had their needs met in a timely way. Medicines were stored safely, people received their medicines when they needed them.

Staff received training to make sure they had the skills and knowledge to carry out their roles. Specialist training such as diabetes and supporting people living with dementia had been completed.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack mental capacity to do so for themselves. The Act requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible.

Staff understood their responsibilities under MCA, people’s capacity had been assessed and when required best interests meetings had been held and recorded. Staff encouraged people to make decisions about their day-to-day care and remain as independent as possible.

People told us that they enjoyed the food. People had a choice of meals and were supported to maintain a healthy diet in line with their choices, preferences and any healthcare needs. People’s health was assessed and monitored. Staff took prompt action when they noticed any changes or decline in health. Staff worked closely with health professionals and followed guidance given to them to ensure people received safe and effective care.

People’s dignity and privacy was maintained by staff. People told us staff were kind and caring. Staff spent time with people and were genuinely interested in them and what they wanted to say. Staff explained how they maintained people’s dignity and how they encouraged choice.

There was a programme of activities available for people to enjoy. Care plans were detailed and had been reviewed regularly and up dated to reflect people’s changing needs.

Information about how to complain was on display in the service. People and

The inspection took place on 16 and 17 August 2016 and was unannounced.

Halvergate House provides nursing care for up to 50 older people, some of whom may be living with dementia. At the time of our inspection there were 37 people living within the home, 34 of which were on a permanent basis. Accommodation is over two floors and the second floor is served with a lift. All bedrooms have en-suite facilities and there are a number of communal areas as well as gardens.

At the time of the inspection, Halvergate House had a manager who had been in post for 12 months but had not yet registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. Shortly after our visit, we received a manager application for this service.

We last inspected this service on 3 and 11 November 2015 where we found that the service was not meeting the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider was in breach of three regulations relating to consent, dignity and respect and good governance. Following the inspection in November 2015, the service failed to send us a plan to tell us about the actions they were going to take to meet the above regulations.

At this inspection in August 2016, we found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches related to dignity and respect, meeting nutritional and hydration needs and good governance.

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.

Effective systems were not in place to monitor the quality of the service and drive improvement. Where issues had been identified by the provider, there were no clear plans in place to rectify those concerns. Not all the issues highlighted in this report had been identified by the service.

Some people experienced a poor service at mealtimes. People were left waiting for their meal and did not receive the assistance they needed at a time they required. Equipment was not always available in a timely manner to assist people to remain independent in eating their meal. People were not offered a choice or explanation of what was being served at the time it was received.

People were not always treated with dignity and respect and their privacy was not consistently maintained. Staff were observed to speak across people they were assisting and talk openly about confidential matters in communal areas. People’s consent wasn’t always gained before assisting them and inappropriate language was used by some staff in relation to the people they supported.

People did not always receive the care and support they required at a time they needed it. Some people told us there were not enough staff to meet their needs. Staff, and some relatives, agreed and told us this impacted on the level of service people received. The provider confirmed that this has been identified and was currently being addressed.

The service had processes in place to help ensure that only those staff suitable to work in health and social care were employed. These included references from previous employers and completing criminal police checks. The staff we spoke with, and the records we viewed, confirmed these were in place prior to staff starting in post.

Processes were in place to help protect people from the risk of abuse. Staff had an understanding of what constituted abuse and how, and where, they could report any concerns they may have.

The risks to individuals had been identified, assessed and managed. These were individual to each person and covered

This unannounced inspection of Halvergate House was undertaken on 13 October 2014. The last inspection was undertaken on 15 and 16 July 2014 and we found breaches of the regulations during that inspection.

At that inspection we were concerned about inadequate staffing levels. We judged this to be a breach of Regulation 22 of the Health and Social Care Act 2008 (Regulated Activities) 2010.

Following this inspection the provider sent us an action plan telling us what action they were going to take to improve.

During this inspection we found that the required improvements had not been met. We subsequently found further breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which correspond to breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Halvergate House provides accommodation and support to a maximum of fifty people, some living with dementia and some who also require nursing care. Halvergate House also provides rehabilitation and respite services. There were thirty nine people living in Halvergate House when we carried out our inspection.

At the time of this inspection the home did not have a registered manager in place. 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. The provider was in the process of recruiting a registered manager. There was an interim manager in place who was managing the services on a day to day basis with assistance from the provider's operational manager.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005, Deprivation of Liberty Safeguards (DoLS), and to report on what we find. The DoLS are a code of practice to supplement the main Mental Capacity Act 2005 Code of Practice. We found the location to be meeting the requirement of the DoLS.

There were insufficient staff on duty in order to meet people’s needs safely and effectively.

People's care and support needs were recorded. However, for some people the information recorded and used by nursing staff did not carry across to care provided by care assistants. For example fluid intake charts and repositioning charts were missing or not completed regularly.

The majority of staff were kind and compassionate, however, people were not always treated with respect and dignity.

Discussions with staff told us they were fully aware of how to raise safeguarding issues.

The provider had a robust, safe and accurate system for ordering, storing and administering medications. Current and relevant professional guidance was followed regarding the management of medicines. Staff had sufficient training to enable them to manage people's medicines safely.

Staff were appropriately trained and skilled. They understood their roles and responsibilities. Nurses had the clinical skills they needed to ensure people’s health needs were met. Staff received regular supervision and appraisals. However, some staff told us they did not feel supported by the management team in the home.

We have recommended that the provider look at how it can improve the lives of people living with dementia.

The provider had a quality assurance system and regularly sought the views of people living in the home. Family members, staff and other health and social care providers also took part in surveys.

People knew how to make complaints and staff knew how to respond to complaints.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) 2010, which corresponded to 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.

Halvergate House can accommodate up to 50 people, which includes people who have a diagnosis of dementia. On the day of our inspection the service were accommodating 46 people, of which 28 had a main diagnosis of dementia, and six people who had a primary health need requiring support, such as Parkinson’s, but had since developed dementia.

During our inspection we spoke with eight people residing in the service, of these six were living with dementia, three people’s relatives and eight staff which included the registered manager. We also left comment cards at the service which provided another forum for the people who used, worked at or had contact with the service to share their views with us on the level of service being provided.

Comments were received from seven people. One person commented that, “All the staff put the wellbeing of the residents first.” Another person wrote, “I cannot praise the staff enough for their patience and care in nursing my (relative) who is in the last stages of dementia… They are attentive at all times and I cannot praise the staff enough for their help at a very difficult time for both my (relative) and myself. I give them 12 out of 10.”

All the people we spoke with were happy with the care they received. One person told us, "I feel at home… It is built to fit us; there is always someone there to help.”

People told us that the service was well led. Relatives told us that the staff and management communicated with them well. They felt staff fully involved them in any decisions and would listen and act on any information given. One relative said that they had developed, “A good relationship with the care and nursing staff as well as the cleaners and catering.” Another relative told us that they had, "Peace of mind,” that their next of kin was being looked after.

People were protected from harm because their individual risks had been assessed and managed. Staff received training in dementia which enabled them to provide safe and professional care.

Care records showed that staff were responsive to changes in people’s needs. We saw that health and social care professionals were consulted with, and staff worked with other providers to ensure people received the right care at the right time.

The manager had an effective way of monitoring and assessing the service provided to people. People told us they felt safe, listened to and were involved in the decisions regarding their care and the running of Halvergate House.

At our inspection in July 2012 we identified concerns about how some people were supported at lunch time. We also found some inconsistencies in the way staff recorded how people were supported and the security of people's records. Following that inspection the provider sent us an action plan that showed how they would make improvements to address our concerns. We carried out this inspection to check that the planned improvements had been made.

Whilst we spoke informally to people and their visitors during our inspection, we did not need to seek their views about the service. However, we observed lunch being served and eaten in one of the home's two dining rooms, spoke with staff and looked at a sample of records maintained about people using the service. We found that most improvements had been made and, where actions were in progress, these were being monitored.

During our visit we spoke with seven people living in the home. We also observed how they were supported by staff. People we spoke with told us that they are happy living in the home. They told us that there was enough going on and that they could join in with activities if they chose to.

People told us that staff provided the support they needed to live their lives. They said that staff were responsive to their needs and knew how to support them. They made comments like “They are jolly good.” “They know how to help me.”

The minutes of residents’ meetings showed that people discussed a range of issues, including menu choices and activities. We saw that those attending provided very positive feedback about how staff communicated with them and that they were very happy with their accommodation.

This inspection was carried out on 3 and 11 November and was unannounced.

Halvergate House is registered to provide accommodation and support to a maximum of 50 people, some of whom also require nursing care. At the time of our inspection there were 32 people living in the home.

The manager had been in post since August 2015 and had submitted an application to become registered with the Care Quality Commission (CQC). We saw that this was currently being processed by CQC’s registration team. A registered manager is a person who has registered with 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 and associated Regulations about how the service is run.

At our last inspection on 13 October 2014, we asked the provider to take action to make improvements to staffing levels and deployment, meeting people’s nutrition and hydration needs and to their systems for monitoring the service. During this inspection we saw that action had been taken and improvements had been made.

We also asked the provider to take action to make improvements to ensure staff treated people with dignity and respect. During this inspection we found that further improvements were still required.

This inspection identified three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches related to the Mental Capacity Act and the appropriate application of Deprivation of Liberty Safeguards. There were also breaches relating to people’s dignity and respect and record keeping.

Improvements had been made to the consistency of staffing levels and we found more appropriate deployment of staff. There were sufficient staff to meet people’s needs and ensure their safety. Appropriate recruitment procedures were followed before people started working in the home, although there were gaps in some people’s employment history.

Nurses and senior staff understood what constituted a safeguarding issue and knew how to contact the safeguarding team when necessary. Other care staff had received training on this subject, knew how to recognise signs of possible abuse and understood they needed to alert senior staff promptly.

Identified risks to people’s safety were recorded on an individual basis, with guidance available for staff to refer to so they could support people safely and effectively.

Nurses and senior staff were proficient with regard to the safe handling and administration of people’s medication and people were given their medication safely, as prescribed.

Staff were being supported well, although formal staff supervisions had not been carried out for many months. Annual appraisals had been completed by the previous manager.

Staff completed basic and mandatory training during their formal induction. Some of the junior staff were lacking in some basic training, with regard to fully respecting people and understanding how to interact and communicate effectively.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005, Deprivation of Liberty Safeguards (DoLS), and to report on what we find. These safeguards protect the rights of adults using the services by ensuring that, if there are restrictions on their freedom and liberty, these are assessed by professionals who are trained to assess whether the restriction is needed.

Not all staff had a clear understanding of the Mental Capacity Act. Best Interests assessments and applications for DoLS had not yet been completed for some people who were subject to some restrictions and whose capacity was in question.

People were provided with sufficient amounts to eat and drink and increased staffing levels meant that people were being supported more appropriately with regard to eating and drinking. People’s weights were monitored, together with their intake of food and drink, although there were gaps in some people’s food and fluid charts.

Prompt action and timely referrals were made to relevant healthcare professionals when any needs or concerns were identified.

Staff generally treated people kindly but they did not always knock on people’s bedroom doors before entering and some staff did not acknowledge people or speak to them before moving them or carrying out a personal task.

Volunteers visited people in the home and people had access to support from independent advocacy services if needed. People could have visitors at any time.

Meaningful activities and social interactions had been limited for some people, due to the absence of the full time activities coordinator. However, people who were more physically able or independent had continued to follow pastimes of their choice.

Assessments were completed prior to admission, to ensure people’s needs could be met and people were actively involved in compiling their care plans. However, although the contents of the care plans were personalised and gave a general description of each person’s needs, they were difficult to follow and it was not easy to locate specific information quickly.

People were able to voice their concerns or make a complaint if needed and were listened to with appropriate responses and action taken where possible.

Consistency and communication had improved throughout the service. The manager was ‘hands on’ and approachable and operated an open door policy. Staff meetings and ‘Resident and Relatives’ meetings were being held more often.

We found that a number of improvements had been made within the service. Other areas were noted to be ‘work-in-progress’ and since the appointment of the new manager, areas of concern were being addressed appropriately.

You can see what action we told the provider to take at the back of the full version of the report.