About the service:

Hartshead Manor Care Home provides accommodation, care and support for up to 55 people over 65 years old including people living with dementia. At the time of our inspection, there were 44 people living at the service.

People's experience of using this service:

¿ People told us they felt safe and well cared for by staff. One person said, “I think they’re very good to me.”

¿ At this inspection, we found some improvements had been made in relation to the management of medicines, the mealtime experience of people living with dementia and how people’s weight loss was managed. However, further improvements were still required and the provider continued in breach of regulations.

¿ We found four breaches of the regulations in relation to safe care and treatment, consent, good governance and staffing. The provider was not always managing the risks involved with people using specialist seating equipment appropriately, checking the temperature of the water before supporting people to have a shower, ensuring the equipment used to help people to move was safe and information in people’s risk assessments was not always detailed or updated. The provider was not always completing decision specific mental capacity assessments and best interest decisions for people who lacked the capacity to make decisions about their care. Staff were not offered regular supervision and appraisal. The provider’s quality assurance processes in place were not effective in identifying the issues found at this service. Some of the issues found at this inspection had already been identified in our previous inspection. The management of the service continued to fail in their oversight and monitoring of the quality of the service and in implementing the changes needed for the service to be compliant with the regulations.

¿ We have made three recommendations in relation to the use of specialist seating equipment, checks on water temperatures and pressure relief for people at risk of developing pressure ulcers.

¿ We received mixed views about the staffing levels at the home.

¿ People enjoyed the meals and their dietary needs had been catered for. This information was detailed in their care plans.

¿ People were supported in accessing healthcare professionals.

¿ People and relatives felt staff were kind and caring and treated them with dignity and respect when providing care.

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

Rating at last inspection:

The service has been in special measures and has been inspected within six months as we state in our guidance. As insufficient improvements have been made and there remains a rating of inadequate for the key question of well-led, the service therefore remains in special measures.

Why we inspected:

When services are in Special Measures they are kept under review and we will inspect the service within six months. This inspection was part of our scheduled plan of visiting services to check the safety and quality of care people received.

Enforcement:

Please see the ‘action we have told the provider to take’ section towards the end of the report.

Follow up:

We will continue to monitor the service to ensure that people received safe, high quality care.

Further inspections will be planned for future dates. We will follow up on the breaches of regulations and recommendations we have made at our next inspection.

We inspected Hartshead Manor on 17 and 25 July and 2 August 2018. This inspection was unannounced.

Hartshead Manor is a care home for up to 55 people. At the time of this inspection there were 49 people living at the home (47 on second and third days). People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Hartshead Manor consists of one building with two floors and had one unit specialised in providing care to people living with dementia.

Hartshead Manor was last inspected on the 4 and 6 April 2017. At that time it was rated requires improvement overall and was in breach of regulations in relation to good governance because of lack of records of people’s food and fluid intake, inconsistent administration of prescribed drinks and poor auditing of water temperatures, care plans and medications. This was the third time this service was rated required improvement. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve their well led domain to at least good. At this inspection we found not enough improvements had been made in the areas identified, the provider was in continuous breach and we found further concerns in relation to safeguarding, safe care and treatment, meeting nutritional and hydration needs and consent.

At the time of this inspection the service had a home manager who had not registered to manage the service. It is a legal requirement that the home has 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.

We found systematic and widespread failings in the oversight, monitoring and management of the service, which meant people did not always receive safe care.

We found concerns about how people’s nutritional and hydration needs were being met and the registered provider was not managing people’s weight loss safely. During this inspection we raised safeguarding concerns in relation to people losing weight.

The management of risks was not always consistent. We found people using specialist pressure relief chairs had not been assessed to use this equipment. We found manual handling risk assessments were not always person centred and lacked detail about how people should be moved.

Medicines were administered in a caring way however we could not be certain these were always administered as prescribed or stored safely.

Mental Capacity Act 2005 assessments and best interest decisions for some people living with dementia were in place however the relevant people had not always been involved. We saw relatives giving consent for decisions without having lasting power of attorney. There was no evidence people were being restricted or receiving care that was not in their best interests.

Staffing levels were not always sufficient to ensure people received the care they needed in a timely way, in particular during meal times.

There was a regular and varied programme of activities at the home and people spoke positively about the activities coordinator however we found people were not offered enough social stimulation throughout the day and spend long periods of time sitting in the lounges.

Staff told us they received training and supervision they needed to provide people with effective care and support however we found some staff had not had their competencies recently assessed and their supervisions were overdue.

The registered provider was in the process of implementing a new electronic system to manage people’s records of care. At this inspection we found

We inspected Hartshead Manor on 4 and 6 April 2017. The inspection was unannounced on both days. The home was last inspected during May 2016 and there were no breaches of regulations at that inspection. During this inspection, we found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to good governance.

This inspection was prompted, in part, by notification of an incident which had resulted in the unexpected death of a person living at the home. This incident is being reviewed by the Care Quality Commission (CQC) in line with our specific incidents policy. Therefore, this inspection did not examine the circumstances of the specific incident.

The information received by the CQC about the incident indicated potential concerns about the way the service managed risk to people. This inspection included an examination of how those risks were managed. We found, since the specific incident, the registered manager had been responsive and had introduced new systems and processes to improve their assessment and management of risks.

Hartshead Manor is a nursing home registered to provide care for up to a maximum of 55 older people. There were 49 people living at the home at the time of our inspection. The home is a converted property providing bedroom and communal areas on both the ground and first floor. The home has a unit which is dedicated to supporting people who are living with dementia.

There was a registered manager in post and this person had been registered with the Care Quality Commission since March 2016. 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.

People told us they felt safe living at Hartshead Manor. There was an up to date safeguarding policy and the registered manager and staff were aware of relevant procedures to help keep people safe. Staff had received safeguarding training and could describe signs that may indicate someone was at risk of abuse or harm.

Risks to people had been assessed and measures put into place to reduce risk. Since the specific incident, improved practices were in place to reduce risks. People’s care plans contained information to enable staff to safely move and handle people and we observed this in practice.

Medicines were stored safely and administered in a kindly manner. However, although we observed people received support to meet their nutritional and hydration needs, records did not always indicate whether people had been given their prescribed drinks, such as those for people nutritionally at risk.

Staff told us they felt supported and had received appropriate induction, training and ongoing support and supervision and the records we inspected supported this.

People were supported to have choice and control of their lives and we observed staff support people in the least restrictive way possible; the policies and systems in the service supported this practice.

We observed staff to be kind and supportive and people told us staff were caring. We observed people’s privacy and dignity was respected.

Care records were person centred and reviewed regularly. However, two care and support staff we spoke with were not aware of the content of care plans. Information was shared between staff to enable continuity of care but this posed a risk that staff were not always fully aware of people’s care needs.

Staff told us they felt supported by the registered manager. Regular meetings such as staff meetings and residents’ and relatives’ meetings were held. Regular audits and quality assurance checks took place, although these were not sufficiently robust and did not identify some areas found during our inspection which required action.

You can see

This inspection took place on 23 May 2016 and was unannounced. The previous inspection, which had taken place on 7 and 9 April 2015, had found the service was in breach of the regulations relating to person centred care, nutrition and hydration and good governance.

The registered manager sent us an action plan to show how these breaches would be addressed. We found improvements in all these areas at this inspection.

Hartshead Manor is a nursing home registered to provide care for up to a maximum of 55 older people. There were 50 people living at the home when we visited to undertake our inspection. The home is a converted property providing bedroom and communal areas on both the ground and first floor. The home has a unit which is dedicated to supporting people who are living with dementia.

There was a registered manager in post and this person had been registered with the Care Quality Commission since March 2016. 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.

People told us they felt safe living at Hartshead Manor but not all relatives shared this view. Two relatives felt there were not enough staff.

Staff had a thorough understanding of safeguarding procedures and staff knew what to do if they thought anyone was at risk of harm or abuse. Risks to people had been assessed and measures were put into place to reduce risks. Staff were recruited safely and trained appropriately. Medicines were stored and administered in a safe way.

Records showed staff had received regular training and support, although one member of staff felt their induction was not adequate because, they told us, they had shadowed other staff for only three hours prior to commencing their duties. Staff received regular supervision. People received support to meet their nutrition and hydration needs. The home environment had improved and was more appropriate to meet people’s needs.

Care and support was not always provided in line with the principles of the Mental Capacity Act 2005 because a person was administered medicines covertly without appropriate assessments being in place.

Staff interactions with people were caring and people appeared at ease in staff presence. There was a pleasant atmosphere in the home. Some staff occasionally used terms that could be perceived as derogatory, such as, “The assists,” referring to people who required assistance.

Care plans were person centred and provided staff with information to provide personalised care and support. Care plans were regularly reviewed. People felt concerns were listened to and acted upon.

Some people who lived at the home, and their relatives, felt the registered manager did not know people well. Staff told us they felt supported by the registered manager. Regular meetings such as staff meetings and resident and relatives meetings were held. Regular audits and quality assurance checks took place, although these were not sufficiently robust. Up to date policies and procedures were in place.

Our inspection team was made up of an inspector and an expert by experience in relation to older people. We spoke with the area manager, deputy manager, a registered nurse and six staff. We also spoke with ten people who lived at the home and two people visiting their relatives.

The inspector also through observation and looking at records used the information they were given to answer the five 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?

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a registered manager on our register at the time.

Below is a summary of what we found. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

We found that safeguarding procedures were in place and staff knew how to recognise, respond and report abuse.

We found the home to be clean, tidy and well maintained.

People were at risk of receiving medication which was out of date.

Is the service effective?

The service had a comprehensive induction process in place for new staff.

Care plans showed where people had seen medical professionals such as the G.P and chiropodist.

Care plans were not always reflective of people’s changing care needs.

Is the service caring?

We did not observe staff consistently supporting people to make simple lifestyle choices.

People we spoke with said staff were kind and caring.

People who lived at the home told us staff were ‘very good’.

Is the service responsive?

On the day of our inspection the activities organiser was on annual leave. There was no evidence of alternative arrangements being in place to support people’s social needs in the absence of the activity organiser.

The service had a complaints procedure which was displayed in the entrance of the home.

We saw the complaints log did not evidence that each complaint had been fully investigated. We also could not see documented evidence of any action taken as a result of the complaint and the outcome..

Is the service well led?

There was no formal analysis of accidents or incidents.

There was a lack of recorded evidence that many of the providers systems for assessing and monitoring the quality of the service were completed on a regular basis. There was also a lack of recorded evidence that issues highlighted from these processes had been addressed.

There was no registered manager in post on the day of our inspection.

During the inspection we observed care on each unit and saw staff interact positively with residents. We spoke with three people and although they could not clearly tell us what they thought, as they had complex needs, they smiled and we saw staff had positive interactions with them. The staff explained peoples history and preferences to us which demonstrated they were aware of the needs of individuals.

We spoke with a visiting relative who told us they had no complaints with staff but they felt the home sometimes seemed a little short staffed. They had no issues with how staff treated their relative. We also spoke with two people who used the service who told us they were well looked after, could get help when they needed it and felt safe in the home. Another person told us they had been to the pub for lunch the week previously and they were looking forward to a boat trip the next Friday.

We found people experienced care, treatment and support that met their needs and protected their rights. People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines. There were enough qualified, skilled and experienced staff to meet people’s needs but the allocation of staff to units in the home needed review and people were not protected from the risks of unsafe or inappropriate care and treatment because records were inaccurate and inappropriate.

We used a number of different methods to help us understand the experiences of people who used the service. This included speaking with people who used the service, speaking with people’s relatives and we observed how staff provided people with care.

Four people told us they were satisfied with the care and treatment they had received at Hartshead Manor.

Four people living at Hartshead Manor told us they liked the staff and one commented the staff were “excellent” and “very respectful”. All indicated to us in different ways that they were informed about their care and treatment.

The acting manager explained they had only been in post for one week and had already identified some shortfalls in the care records. However our inspection demonstrated that people had not experienced care, treatment and support that met their needs and protected their rights. Systems had not been followed to ensure people had received the correct medication. Improvements were needed to the records to ensure people were protected from the risks of unsafe or inappropriate care and treatment.

People said they were visited by the staff before they came into the home and their care was agreed.

Staff were seen to respect people’s wishes, and people told us that staff respect their privacy, dignity and independence.

People told us, “most of the staff are very nice and nothing is too much trouble”.

Another person said, “The staff on night duty are lovely, very good, and yes we are well looked after”.

People said the activities person was good, but there was not always enough going on during the day.

People told us that most of the time there were enough staff to look after people however, at lunch time people also said that they could do with another member of staff as sometimes they had to wait to go to the bathroom.

One of the staff said, “Since the manager has come, he sees things that need doing and the home is becoming lovely. He is supportive. I could definitely go to him if I had any concerns, and he would sort them out”.

Achievements by the home include:

‘Scores on door’ Awarded a 4 out of 5 star rating, which is a food hygiene national award, awarded by the council.

The inspection of Hartshead Manor took place on 7 April 2015 and was unannounced. We also visited a second time on 9 April 2015, this visit was announced. We previously inspected the service on 29 September 2014 and at that time we found the provider was not meeting the regulations relating to respecting and involving people who use services, management of medicines and assessing and monitoring the quality of service provision. We asked the registered provider to make improvements. The registered provider sent us an action plan telling us what they were going to do to make sure they were meeting the regulations. On this visit we checked to see if improvements had been made.

Hartshead Manor is a nursing home currently providing care for up to a maximum of 55 older people. There were 43 people living at the home when we visited. The home is a converted property providing bedroom and communal areas on both the ground and first floor. The home has a section of the home which is dedicated to supporting people who are living with dementia. When we inspected Hartshead Manor there were 15 people living within this unit.

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

People who lived at Hartshead Manor told us they felt safe. Staff had received training in how to safeguard vulnerable people from the risk of harm and abuse.

People’s medicines were stored and administered safely. Staff who administered people’s medicines had all received training and an assessment of their competency had been completed.

We found recruitment practices were safe. Staff told us new staff had been recruited and the home was using less agency staff as a result. When we asked people if there were enough staff to meet peoples needs, feedback was mixed.

Feedback from people who lived at the home was positive about the meals they received. Lunchtime in the ground floor dining room was a positive experience for people. However, in the upstairs lounge/dining area we saw people were not always provided with adequate and timely support with their lunch time meal. Recording of people’s dietary and fluid intake was inconsistent.

This demonstrated a failure to protected people from the risks of inadequate nutrition and dehydration. This was a breach of regulation 14 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The registered provider had a system in place to support new staff. We saw evidence to support staff had received supervision to monitor their performance, development needs and training.

The communal area for people who were living with dementia was not homely and items to engage people’s attention were not readily available.

We saw a number of interactions between staff and people who lived at the home which were kind and caring. We heard staff explaining to people and offering them choices about what to eat, drink and where to sit. Staff were able to tell us about the actions they took to maintain people’s right to privacy and dignity.

There was a regular programme of activity in the ground floor lounge, however, we did not see any form of meaningful activity in the upstairs lounge. There was a lack of information about people’s life history in care records and care records did not consistently provide enough details to ensure peoples care and support was person centred.

This evidenced a failure to ensure that care and support was planned and delivered to meet the individuals need. This was a breach of regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The registered provider had a system in place to monitor complaints although verbal and low level concerns were not logged.

When we asked people who lived at the home who was managing the home, they were not able to tell us. Staff told us the recent changes at the home had led to improvements at the service.

Audits were in place but audits of peoples care records had not been completed on a regular basis. We found people’s care and support records were not always reflective of their current needs.

These examples demonstrate a failure to identify, assess and manage risks relating to the health, welfare of people who live at the home. This also demonstrates a failure to ensure accurate and complete records are maintained for each person. This was a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Regular meetings were held with staff, people who lived at the home and their relatives. Quality feedback forms were due to be distributed following the commencement of the new manager.

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