This inspection took place on 18 and 19 December 2018 and was unannounced on the first day. We previously inspected the service in April 2018. The service was not meeting all of the requirements of the regulations at that time and was rated ‘requires improvement’.

Following the last inspection, we asked the provider to complete an action plan to show how and when they would improve the key questions safe, effective, caring, responsive and well led to at least good.

Holmers 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.

Holmers House accommodates 48 people in one adapted building. The service accommodates 16 people across three separate units, each of which have separate adapted facilities. All of the units specialise in providing care to people living with dementia. At the time of our inspection there were 33 people using the service.

The service had 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.

At out last comprehensive inspection on 10 and 11 April 2018 we identified a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) 2014. The service failed to provide person centred care that met people’s needs and reflected their preferences. This inspection found a continued breach of Regulation 9 and a breach of Regulations 12, 13 and 17 of the Health and Social Care Act 2008 (Regulated Activities) 2014.

People were not supported to have maximum choice and control of their lives. Staff did not support them in the least restrictive way possible; the policies and systems in the service did not support this practice.

We received mixed views from people about feeling safe living at Holmers House. Several people confirmed that they were still susceptible to falls, however, were able to confirm that their environment was safer for them than where they lived previously. Some people told us they had been hit by another person at Holmers House.

We observed medicine administration and checked the stock levels of prescribed medicines. We found some people had been without their medicines due to insufficient stock. We saw some people were on fluid charts due to their assessed needs. The system used by the service to record people’s fluid intake had been incorrectly calculated. This meant people were at risk of dehydration and we made the registered manager aware of this during our inspection.

The provider did not have systems in place to ensure the service offered quality care and support. Some people were at risk of harm from other people living at Holmers House. Risks to people were not managed safely. Providers are required by law to notify us of significant events that occur in services. We found safeguarding alerts had been made by the service and managed appropriately.

People told us there was a choice of meals and said there was plenty to eat. Staff were aware of the support people required during meal times.

We found four breaches of the Regulations. Full information about our regulatory response to the more serious concerns found during inspections, is added to reports after any representations and appeals have been concluded. We found one domain being rated inadequate, we will re-inspect within six months and if this or any other domain is then rated inadequate, the service will go into special measures.

The inspection of Holmers House took place on 10 and 11 April 2018 and was unannounced. This was a scheduled inspection, which followed up breaches from the previous inspection when the service was rated inadequate and placed in special measures.

Following the last inspection, we met with the provider and asked them to complete 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. During this inspection we found some improvements had been made. However, we found a continued breach of regulation in relation to person centred care.

Holmers 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.

Holmers House accommodates 48 people in one adapted building. The service accommodates 16 people across three separate units, each of which have separate adapted facilities. All of the units specialise in providing care to people living with dementia. At the time of our inspection there were 33 people using the service.

The service requires a registered manager to manage the service. At the time of our inspection a registered manager was not in post. The service was being managed by a registered manager from another location.

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 we spoke with told us they felt safe living at Holmers House. One person told us, “I am grateful for a place like this, it is safe, no-one interferes and they leave you alone.”

Staff had received training in the administration of medicines and were assessed as competent to carry out this role. However, we found medicines were not always managed appropriately and some people had not always received their medicines due to insufficient stock.

Records relating to recording of food and fluids were not always completed accurately. People on restricted fluids did not have their daily intake recorded accurately for staff to see how much they had received.

People were not always supported to have maximum choice and control of their lives; policies and systems did not support this practice.

Staffing levels were adequate to ensure people received care in a timely manner. Staff had received training in topics such as moving and handling, mental capacity and fire safety. Regular supervisions and reviews of performance had not been carried out in the past. However, there was now a system in place to ensure that staff received adequate support. Staff told us they felt supported by the management of the service.

Staff had received training in safeguarding and told us they knew what to do if they suspected someone was being inappropriately treated. We spoke with a member of staff who told us they had reported poor care practice in relation to medicine administration.

The provider had robust recruitment files in place to ensure only suitable staff were appointed. Files we viewed had proof that Disclosure and Barring Service checks (DBS) had been completed.

We found people’s care was task-focussed and not person-centred.

One relative we spoke with told us, “Staff congregate in corners with no awareness of what is going on.” The delivery of high quality care was not assured by the culture of the service.

People told us the food was good and they were given an option. People with swallowing difficulties had pureed or soft food.

People had no social stimulation and were asleep in lounges for most of the day. One relative told us they took their relative to a day centre to give them some form of

Holmers House is a purpose-built residential home divided into three care units, each with 16 places. The service supports people who are living with dementia. One unit is on the ground floor whilst the other two units are on the first floor. At the time of our inspection there were 41 people living in the home.

The inspection of Holmers House commenced on 16 August 2017 and was unannounced. This was a scheduled inspection that followed up breaches from the previous inspection when the service was rated requires improvement. We discovered on arrival at the service that the registered manager was not currently in post and was not working at the service. We were told that this was due to the provider identifying lack of progress in working towards the action plan to address requirements from the previous inspection. The deputy manager was managing the service in their absence. We were aware that a compliance company were working with the provider to ensure improvements were made. We were told that a manager from this company would be in place at the service the week following our inspection visit.

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 carried out on 31 May 2016 identified breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014 and found a number of improvements were required at the service. We asked the provider to take action to make improvements in relation to the management of medicines, meeting nutritional and hydration needs, ensuring the premises were clean and carrying out care and treatment in conjunction with people’s needs. The provider sent us an action plan setting out how they would take action to address the breaches in regulations.

Following this inspection, we do not consider that the service has attained compliance with regards to the previous breaches of regulations.

People using the service were not always treated with dignity and respect. We observed undignified care practices during our inspection. People’s rights and choices had not always been respected.

Staffing levels were not assessed using a dependency assessment tool. Relatives told us and our observations showed that care and support was not always provided in a timely manner. We received different views from people and relatives we spoke with about the staffing levels. Some told us it was satisfactory whilst others said sometimes there was only one member of staff available. We observed staff did not identify themselves by wearing their name badges. Comments from relatives were, “none of your staff wear name tags which can cause problems identifying people.”

The quality assurance systems in place were not effective. We found continued issues as part of our inspection relating to accurate completion of records. Quality assurance systems had identified some of the issues; however it was not always clear that they had been acted upon.

A visiting professional told us simple instructions were not followed by staff. They also commented on the lack of leadership and that there did not appear to be anyone managing the units.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible. Policies and systems were in place regarding the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). We observed practice on one unit which did not afford people the right to make decisions about their care.

The service had documents which were used to record food and fluid intake for people who may be at risk of dehydration and malnutrition. However, examples we reviewed were not always completed effectivel

The inspection took place on 31 May and 2 June and was unannounced.

The previous inspection was carried out on 10 June 2014 and was fully compliant at that time.

Holmers House is a purpose built residential home divided into three care units each with 16 places. Two units are on the ground floor whilst the other unit is on the first floor. At the time of our inspection there were 45 people living in the home.

There was a registered manager in place at the time of our visit. 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 were not able to speak to many people at Holmers House but these were some of the comments we received. One person told us, they liked living in the home and said, “It’s ok as long as I have my music on”. Another person told us, “It’s alright but I would rather be at home”. During both days of our inspection we observed people appeared happy and content living in the home.

Staff reported lack of support and supervision. One member of staff told us they had supervision sometime last year but could not remember when. Another member of staff told us, “We are short- staffed and it is difficult trying to keep my eye on what the agency staff are doing.”

The risk assessment process to identify risks to people and how they were to be eliminated or managed were not always being carried out or recorded. This meant people were not always being protected from identifiable risks to their health and safety. People’s care plans did not always reflect the care that was carried out.

Staff had received training in topics such as fire safety, manual handling and mental capacity.

The home had agency staff who work in the home due to difficulty in recruiting permanent staff. However, the home tried to ensure the same staff were requested from the agency.

Staff had received training in the administration of medicines. Medicines were administered safely and in a timely way. However, medicines were not stored safely within the correct temperature as advised by the manufacturer.

Activities were planned in accordance with the people who were able to participate. We saw people participating in activities on both days of our visit.

We observed staff to be rushed and task-focused and had little time to positively interact with people.

Internal audits had not identified areas for improvement. We made a recommendation in relation to audits.

The service did not have a cleaning schedule to identify areas that had been cleaned or were in need of cleaning. The kitchen had expired food stored in the fridge and we could not see any evidence that the kitchen had been cleaned.

We found a number of 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.

A single inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what people who used the service and the staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

This is a summary of what we found:

Is the service safe?

We found people were protected against the risk of harm in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). Where people were assessed as lacking capacity, appropriate procedures were followed to ensure arrangements were in people’s best interests and in line with legal guidelines. The provider was aware of DoLS changes and had contacted the local authority for guidance.

We saw incidents involving people with challenging behaviour which had been identified as a risk. We saw appropriate risk assessments where in place and professional input was sought to ensure people were safe. Where incidents happened, these were reported to the relevant authority and care plans and risk assessments where updated accordingly. We found safeguarding posters for people who used the service, staff and visitors were readily available throughout the service containing the local authorities contact details and how to raise a concern.

Is the service effective?

We saw regular audits where undertaken to ensure the quality of service provision. Where it was assessed that a person had refused to take their medication, appropriate mental capacity assessments were undertaken and professionals where involved to find the least restrictive manner to administer medication without unnecessarily depriving the person of their liberty. We found the provider had effective recruitment procedures in place when recruiting new members of staff.

Is the service caring?

We saw examples of good person centred practice during our visit. People where spoken to in a kind and friendly manner. One person told us “The staff are all lovely.” We saw people were supported to go outside at their request as it was a warm day. We observed one person dancing with a member of staff which they appeared to enjoy. Where people requested items from staff, these where met promptly, for example, custard instead of ice cream and salt with their lunch. We saw people participated in activities at their discretion. One person told us “I played bingo earlier and I won!”

Is the service responsive?

We saw staff were visible and available during our observations on all units. Where people made requests these were met promptly. On our arrival we saw people requesting breakfast and saw their choices were met. We saw staff reacted promptly when a person had an accident in the communal area. Care plans were updated regularly with any changes to people’s care.

Is the service well-led?

Regular audits where undertaken within the service and residents and staff meetings where held which fed back into the service. We saw complaints were fed back into the service and accidents and incidents were analysed to identify trends or patterns. Staff told us they felt management where approachable and supportive however they would like them to be more visible.

We talked to ten people who used the service, five staff members and one family member during the inspection. We observed that staff knew the people they were supporting and allowed them the time they needed to do or say something. We noticed that the importance of giving sufficient time was also recorded in care plans.

People told us they were well cared for by staff. We observed positive communication between people and staff. One person said: “The staff are very nice.” Another person told us “We get a lot of help.” A staff member told us that “The care for residents is awesome.”

The home was spacious and clean with individual en suite rooms and pleasant gardens. One person told us “I’m very comfortable, very happy here.”

Most of the people using this service have complex needs and experienced problems in communicating their views on the service directly to us. We used a number of different methods to help us understand the experiences of people using the service.

We observed activity in the service at various points in time over the course of the day. In one care unit we used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

We saw that staff were generally attentive and provided support to people when required. Two people told us they were well cared for by staff. One person said “They look after you very well here”. Another person said “The staff are very kind”.

We spoke with one person about their medication. The person told us that the medicines were being given to them correctly.

Holmers House is a purpose built residential

care home.

The accommodation is divided into

three care units, each with 16 places. One care unit on the ground floor and two units on the first floor. All rooms had en-suite facilities.

Most of the people using the service had dementia.

The home was staffed 24 hours a day.

People told us that they were happy living in the home. They said they liked the activity and the company. People said they got help when they needed it. People told us that they thought it was a nice bright home.

The people we spoke to were comfortable talking to us about their lives in general and about things that were happening around the home on the day of our visit. They were relaxed and looked comfortable living at Holmers House.

People expressed satisfaction with the food served in the home.

A carer visiting the home told us that on occasions they had noticed that people in the lounge had been left unattended by staff for some time.

Another carer, also visiting, told us that the staff always kept them informed of any changes to their relatives care and treatment.