The inspection took place on 10,16 and 18 October 2018 and was unannounced on the first day and announced on the second two days. At the last inspection on 27 November 2017 the registered provider was not meeting the regulations related to person centred care and good governance. The service was rated requires improvement in all the key questions.

Following the last inspection, the registered provider sent us an action plan to show what they would do and by when to improve the key questions safe, effective, caring, responsive and well led to at least good. At this inspection we checked to see whether improvements had been made and found the registered provider was not meeting the regulatory requirements relating to safe care and treatment, consent and good governance.

Home House 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.

Holme House Care Home provides accommodation for up to 68 people with residential, nursing and dementia care needs. The home has three distinct units over three floors. At the time of our inspection 61 people were using the service.

A registered manager was 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 2008 and associated Regulations about how the service is run.

We found risks were not always assessed and measures not always put in place to reduce these risks. Incidents and accidents were recorded, however learning from these incidents was not always evident.

We found the systems for managing people’s medicines was not always safe because the administration of topical creams was not consistently recorded. Staff competency checks on the administration of medicines were up to date.

Emergency procedures were robust to protect people should the building need to be evacuated.

We found adequate numbers of staff were deployed to meet people’s assessed needs. Feedback from people, relatives and community professional about whether there were adequate numbers of staff deployed was mixed and some people said use of regular agency staff at night reduced consistency for people.

Staff had a good understanding of how to safeguard adults from abuse and who to contact if they suspected any abuse. Safe recruitment and selection processes were in place.

People were not always supported to have maximum choice and control of their lives because decision specific mental capacity assessments and best interest decisions were not always in place to ensure people’s rights were protected.

Staff told us they felt generally supported and they received some supervision, training and appraisal to meet their development needs. Staff had received an induction and role specific training, which ensured they had the knowledge and skills to support the people who lived at the home.

Most people told us they enjoyed their meals and meals were planned around their tastes and preferences. People were supported to eat a balanced diet and action was taken where people’s nutritional intake had declined.

People were supported to maintain their health and had access to healthcare professionals and services.

Positive relationships between staff and people who lived at Holme House were evident. Staff were caring and supported people in a way that maintained their dignity, privacy and diverse needs.

Some care records contained detailed information about how to support people, however other care records had not been updated to provide person centred support. End of life care plans were in place for some people using the service to record their preferences.

Some activities were provided for people in line wi

The inspection of Holme House Care Home took place on 27 November and 4 December 2017. We previously inspected the service on 8 and 13 February 2017; at that time we found the registered provider was not meeting the regulations relating to dignity and respect, safe care and treatment, nutrition and hydration, staffing and good governance. We rated them as inadequate and placed the home in special measures. We asked the provider to complete an action plan to show what they would do and by when to improve the service. The purpose of this inspection was to see if significant improvements had been made and to review the quality of the service currently being provided for people.

Holme House is a ‘care home’. 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. Holme House is a nursing home currently providing care for up to a maximum of 68 older people. The home has three distinct units Memory Lane, Oakwell Avenue and Redhouse Lane, providing care and support for people with nursing and residential needs including people who are living with dementia. On the days of our inspection 61 people were living at the home.

The service had 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 2008 and associated Regulations about how the service is run.

Staff had received training in safeguarding people from the risk of harm or abuse and understood their responsibilities in reporting any concerns to a senior member of staff.

Information recorded in moving and handling records was detailed however, it was not always clear which hoist sling belonged to which person.

External contractors were used to service and maintain equipment. Internal checks were completed on the fire system. People had a Personal Emergency Evacuation Plan in place but these were not always an accurate reflection of their current needs and we were not able to establish from the records available that staff had completed a simulated fire drill.

Staff were recruited safely and we saw people’s needs were met in a timely manner.

The temperature at which some medicines were stored was not always appropriate but action was taken by the registered manager to address these concerns. The recording of creams was not robust; there was a lack of information available for staff to ensure they were applied correctly. We have made a recommendation regarding the management of creams.

The registered manager had implemented a system to review accidents and incidents. This provided an opportunity to address shortfalls and reduce future risk.

Policies referred to legislation but they did not always reference current good practice guidance.

New employees received induction but there was currently no facility at the home to support staff who had no previous care experience to access the Care Certificate. Staff received training and a programme was in place to provide further training for staff in regard to supporting people who were living with dementia. Not all staff had received regular supervision, the registered manager had begun to complete staffs’ annual appraisal.

Most people we spoke with told us the food was good. People were able to choose where they wanted to eat and were supported appropriately by staff. Where staff recorded people’s diet and fluid intake, improvements needed to be made to ensure the records were accurate and detailed.

People received support to access other healthcare professionals.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the polici

The inspection of Holme House Care Home took place on 8 and 13 February 2017. We previously inspected the service on 5 and 15 October 2015 at that time we found the registered provider was not meeting the regulations relating to safe care and treatment. 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.

Holme House is a nursing home currently providing care for up to a maximum of 68 older people. The home has three distinct units providing care and support for people with nursing and residential needs including people who are living with dementia. On the days of our inspection 52 people were living at the home.

The service had a manager in place but they were not yet 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.

People told us they felt safe and staff understood their responsibility in reporting concerns about harm or abuse.

Not all aspects of people’s care and support had been robustly assessed. We found inconsistent information regarding the moving and handling needs of one person, we also found a lack of information in their care plan regarding the equipment they used. One person had had a number of falls but the care plan did not detail how staff were to help the person to get up from the floor.

On both days of our inspection, no fire extinguishers were available on the corridors of Memory Lane. Cleaning materials were stored in an unlocked kitchenette cupboard.

There were insufficient numbers of suitably deployed staff to meet people’s needs in a timely manner and people were left unsupervised.

Some aspects of staffs’ recording in regard to medicines administration needed to be improved.

Not all areas of the home were clean.

Staff received regular training but some staff said they would benefit from more specific training around supporting people who exhibited behaviour which challenged others.

The majority of the staff had competed training in the Mental Capacity Act 2005 (MCA) but care records did not evidence the decisions made where people lacked capacity had been taken in line with the requirements of the MCA 2005.

People told us they were not satisfied with the meals at Holme House and our observations of meal times raised concerns about the suitability of the food for some people and the skills and deployment of staff to meet people’s needs. People did not receive adequate support to eat their meals.

People and relatives said the care they received was acceptable but people said the care could sometimes be a bit inconsistent. Staff told us they did not have time to read people’s care plans and staff were not always aware of people’s needs.

We noticed that where people had limited ability to express themselves, staff made choices for them and did not always involve them in making decisions. People were not always supported in a way which maintained their dignity. We saw people using their fingers to eat scrambled eggs with beans and sponge with custard.

Records relating to the care people received as they entered the closing stages of their lives lacked evidence that people or their families had been supported with this aspect of their care. We have made a recommendation in regard to end of life care planning and record keeping.

People’s care plans were person centred but where people’s care needs had changed, their care planning records were not always updated to reflect those changes. People’s food diaries did not provide adequate detail of the food they were offered. Where care plans instructed staff to weigh peopl

This visit was carried out by two inspectors, an expert by experience and a specialist advisor in relation to older people. We spoke with the registered manager, a care co-ordinator, the deputy manager and 7 staff. We also spoke with 3 people who lived at the home and 2 visitors.

The inspectors, the expert by experience and the specialist adviser, 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?

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?

There were systems were in place to monitor the service. However, we found that some of these monitoring tools had not been completed with appropriate frequency.

We found the home to be clean with no offensive odours in communal areas.

We found some issues regarding staff training at the service, where training had either not been completed by staff or refresher training was overdue.

Is the service effective?

Not all staff had received up to date training and supervision. Feedback from staff was mixed in regard to how well they felt supported.

People’s care records were not always assessed with their involvement or with the involvement of relatives and other healthcare professionals.

We found that people’s care records were not always up to date and, at times, contained incorrect or inaccurate information.

Is the service caring?

People were supported by kind and attentive staff. We saw care assistants showed patience and gave encouragement when supporting people. People we spoke with said staff were kind and caring.

People’s preferences, interests, aspirations and diverse needs had not been recorded in all care records.

Is the service responsive?

The manager had taken steps to look into reasons why the service had experienced a high turnover of staff over the previous few months.

People did not partake in many activities at the home. On the day of our visit we observed people sitting in lounges watching television. We also observed people who used the service sitting in lounges with no interaction from staff members for a considerable length of time. People who lived at the home told us they would like more activities to partake in. We found pieces of artwork had been completed by people who used the service decorated the corridors, although some of this artwork was inappropriate for the client group. Artwork included small, blank canvasses with a piece of paper stuck to them with a year printed on them, printed pictures of teddy bears and beach balls and tissue paper and glitter string stuck to walls.

Is the service well led?

Audits at the home were not up to date. There was no formal analysis of accidents or incidents.

There was no documented evidence of the provider’s management of the service.

Staff told us they were clear about their roles and responsibilities.

During the inspection we had the opportunity to speak with people who used the service, relatives, the activities coordinator, the manager, a domestic cleaner, the care coordinator, a care assistant and other staff members.

The people who used the service told us they were looked after well and felt safe with the care and treatment provided. Their comments included: "It’s alright here", “They are good to me” and “It’s nice to live here”.

We found that the service had appropriate systems in place to ensure consent was gained before staff proceeded with personal care.

We saw that there was an appropriate system in place for listening to and acting on people’s comments and concerns.

We spent time observing the three lounges and dining areas during the day of our inspection. We looked at how people spent their time and how staff interacted with people. The interactions we saw between staff and people who used the service and visitors were respectful.

During the visit we had the opportunity to speak with four people who used the service and two relatives. Everyone told us they were "very happy" with the care and support provided at Holme House. They said the staff were "wonderful", "very approachable" and professional and caring. People told us they could make choices and decisions about how they wanted to spend time at the home and staff encouraged them to be fully involved making decisions about their care and treatment.

A relative told us they were involved in discussions and decisions about their relatives care needs and were kept informed about any changes. They said "the staff are great my relative is well looked after here." People who lived in the home and their relatives said the food was very good and the home was clean, warm and comfortable.

Many of the people who use this service could not tell us directly about their experiences due to a variety of complex needs however, staff observed had good relationships with these people and people they were seen to have their privacy, dignity and independence respected.

The activities person was day off on the day of our visit however; people were seen to be involved in various activities and were relaxed as they interacted with staff.

The purpose of this inspection was to check up on a compliance actions made at the previous inspection.

People who use the service were not able to tell us about their views of the service they receive. However, through our observations, we saw that people seemed confident in their surroundings and in their interactions with staff.

At inspection we spoke to a number of people who live at Holme House. The people that we spoke to explained that they were happy with the care they receive, and that the staff treat them with dignity and respect at all times. People said that they liked the food they received and that their rooms were adapted and equipped appropriately for their needs.

The inspection of Holme House took place on 5 October 2015 and was unannounced. We also visited a second time on14 October 2015, this visit was announced. We previously inspected the service on 1 September 2014 and, at that time; we found the registered provider was not meeting the regulations relating to respecting and involving people who use services, supporting workers, assessing and monitoring the quality of service provision and records. 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.

Holme House is a nursing home currently providing care for up to a maximum of 68 older people. The home has three distinct units providing care and support for people with nursing and residential needs including people who are living with dementia. On the days of our inspection 56 people were living at the home.

The service had 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 2008 and associated Regulations about how the service is run.

People told us they felt safe and staff understood their responsibilities in keeping people safe from the risk of abuse.

Risks to people’s welfare had not been robustly assessed and relevant risk assessments had not always been implemented. Although accidents and incidents were analysed the analysis did not take into account the location or time of the accident. A personal emergency evacuation plan (PEEP) had been completed but this was stored on the computer and was not readily available for staff in the event of an emergency. We were unable to evidence that all the staff at the home had participated in fire drill training.

This demonstrates a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

There was a procedure in place to ensure staff recruitment procedures were thorough and a dependency tool was used to assess the number of staff required by the home.

We saw peoples medicines were administered safely and the registered provider had implemented an audit system. However, this audit did not assess all aspects relating to the safe management of people’s medicines.

Staff were supported in their role through supervision and training.

Our discussions with the registered manager and staff showed they had an understanding of the Mental Capacity Act 2005 and how they would act in peoples best interests if they lacked capacity to consent.

Peoples feedback regarding the meals they were served was mixed. However, on the day of our inspection we did not evidence any concerns with the meals provided to people.

We have made a recommendation about dementia friendly enviroments.

Staff were kind and caring. We saw staff respected people’s privacy and took steps to maintain people’s dignity.

Care plans were detailed and person centred but not all the records we looked at detailed the name of the person or the date. Life history documentation was incomplete in three care plans.

The registered provider had a complaints procedure in place.

The home had an experienced registered manger in post. Feedback from staff about the management of the home was positive and the registered provider had a system in place to continually monitor the quality and safety of the service people received. This included management reports, staff meetings and service user’s feedback.

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