About the service:

Holmwood Care Centre is a care home that provides nursing and personal care for up to 60 people over three floors within one large adapted building. The home is divided into a dementia care unit and a residential care unit on the ground floor, and a nursing care unit on the first and second floors. At the time of our inspection visit, 47 people were living at the home.

People's experience of using this service:

• The provider had not always told us about safeguarding issues involving people who lived at the home.

• People’s rights under the Mental Capacity Act 2005 were not always fully promoted.

• We were not assured people always received personalised care that was responsive to their needs.

• Risks associated with the premises, equipment in use and people’s individual care needs had been assessed, reviewed and plans put in place to manage these.

• The provider had measures in place to protect people, staff and visitors from the risk of infections.

• People received their medicines from nurses and trained staff who maintained up-to-date medicines records.

• The provider followed safe recruitment practices to ensure prospective staff were suitable to work with people.

• Staff received ongoing support, training and supervision to enable them to work safely and effectively.

• People’s care and support needs were assessed and kept under regular review in order to achieve positive outcomes for them.

• People were supported to make choices about what they ate and drink, and any risks associated with their nutrition or hydration were assessed and managed.

• Steps had been taken to adapt the home’s environment to the needs of people living with dementia, and the provider planned to undertake further work in this regard.

• People’s health needs were assessed, and they had support to access community healthcare services.

• People were treated with kindness, empathy and respect by staff and management.

• Staff recognised their role in promoting equality and diversity within the service.

• The views of people and their relatives on the service were actively encouraged and acted upon.

• People had support to participate in a range of social and recreational activities.

• The provider had a complaints procedure in place to ensure all complaints were dealt with fairly.

• Staff worked with community healthcare professionals to ensure people’s needs and wishes were met as they approached the end of their lives.

• The provider had quality assurance systems and processes in place, designed to enable them to identify and address quality concerns within the service.

• The majority of staff felt well-supported by an approachable management team.

We found the service met the requirements for 'Good' in two areas, and 'Requires improvement' in the three other areas. For more details, please see the full report which is on the CQC website at www.cqc.org.uk.

Rating at last inspection: At the last comprehensive inspection, the service was rated as 'Requires improvement' (inspection report published on 11 January 2018). At this inspection, the overall rating of the service remained the same.

Why we inspected: This was a planned inspection based on the service's previous rating.

Enforcement: Full information about CQC’s regulatory response to the more serious concerns found in inspections and appeals is added to reports after any representations and appeals have been concluded.

This inspection took place on 19 and 27 October 2017 and was unannounced.

The provider of Holmwood Care Centre is registered to provide accommodation for up to 60 people with personal and nursing care needs who may have physical disabilities or people with dementia. At the time of this inspection 55 people lived at the home.

There was a registered manager in post and they were present during our inspection. 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 quality monitoring checks the provider had in place did not consistently ensure staff followed safe and best practice in all areas. The management of people’s identified risks and the equipment required did not consistently reflect people needs accurately. In addition, the management of people’s creams were not consistently applied as prescribed to meet their individual needs.

We have made a recommendation about the management and administration of people’s medicines and that mattresses are systematically monitored to ensure the correct settings are adhered to.

Furthermore some care records did not ensure clear guidelines were provided for staff to follow. This had the potential for important care instructions not being passed on to all staff and could impact on the care provided. The shortfalls in these areas had not been consistently identified in the provider’s own quality checking arrangements. However, the registered manager ensured immediate actions were taken during the first day of our inspection and followed these through in an action plan they produced which they gave to us on the second day of our inspection.

We have made a recommendation about people’s individual needs being consistently documented in care plans with the provider implementing improved methods to quality check care plans.

Staff did not always reflect there was a culture of reporting poor infection control practices which the registered manager saw and took action to remedy. There was also a culture of some of the staff team in consistently taking unplanned absences from work. This had already been identified by the registered manager as one of their biggest challenges since they had been in post but had not been fully resolved. However, the provider’s procedures needed to be utilised so changes in staff culture were improved to benefit people who lived at the home.

People had various reasons for feeling safe while they lived at the home which included staff who had knowledge of their care needs and being available to support their requests. The differences in the staff team’s skills had been assessed alongside the numbers of staff required so people’s care and safety was not compromised. The registered manager continually reviewed staffing arrangements to ensure they continued to meet people’s individual needs and changes in these. This process assisted the registered manager to be flexible and there were proposed plans to increase staffing numbers at night.

People were complimentary about how staff who knew them well supported them with kindness and thoughtfulness. People were less enthusiastic about agency staff as they felt they were not as familiar with their particular needs. Where staff vacancies existed the registered manager showed they were taking action by methods of the on-going recruitment of staff to decrease the need for agency staff.

People were confident their care and health needs were effectively responded to and met by staff who had the knowledge to do this. Staff had been provided with the training and support they required to support people's specific needs. Staff also worked closely with healthcare professionals where required to meet people’s needs. People enjoyed their mea

We carried out an unannounced comprehensive inspection of this service on 7 December 2016.

The home is registered to provide accommodation and personal care for adults who require nursing care and who may have a dementia related illness. A maximum of 60 people can live at the home. There were 52 people living at home on the days of the inspection.

There was a manager in post, who was in the process of applying to become the registered manager with us. 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 the last inspection on 26 January 2016, the provider needed to make improvements and we rated the following key questions of safe, caring, responsive and well led as requires improvement. On this inspection we found that improvements had been made with the staffing team as people received care from staff that were respectful, care that was and responsive to their needs.

People told us that they felt safe in the home and felt the staff helped to keep them safe. People were not concerned about the risk of potential abuse and staff told us about how they kept people safe. During our inspection staff were available for people and were able to support them by offering guidance or care that reduced people’s risks. However, people who needed assistance with their meals were not always supported consistently. People told us they received their medicines as prescribed and at the correct time. They also felt that if they needed extra pain relief or other medicines these were provided.

People told us staff knew how to look after them. Staff felt their training reflected the needs of people who lived at the home. Nursing staff had clinical supervision which they felt supported and helped them in providing care to people who lived at the home.

People were supported to eat and drink enough to keep them healthy. We found that people’s health care needs were assessed, and care planned and delivered to meet those needs. People had access to other healthcare professionals that provided treatment, advice and guidance to support their health needs.

People told us and we saw that their privacy and dignity were respected and staff were kind to them. People received support to have their choices and decisions respected and staff were considerate of promoting their privacy and dignity.

People had been involved in the planning of their care or relatives felt they were involved in the care of their family member and were asked for their opinions and input. People told us staff offered encouragement and supported them with a variety of things to do.

People and relatives we spoke with told us they were aware of who they would make a complaint to and were confident to approach the manager if they were not happy with the care. The provider had reviewed and responded to all concerns raised.

Regular checks had been completed to monitor the quality of the care that people received and look at where improvements may be needed. Management and staff had implemented recent improvements which need to be regularly reviewed to ensure people’s care and support needs continued to be met. The management team were approachable and visible within the home which people and relatives liked.

At our previous comprehensive inspection of this service on 5 May 2015 there was a breach of three legal requirements. After the inspection, the provider wrote to us to say what they would do to meet the legal requirements in relation to person-centred care Regulation 9, staffing Regulation 18 and safeguarding service users from abuse Regulation 13 of the Health and Social Care Act 2008 (Regulated activities) Regulations 2014.

We inspected the provider to see if they were now meeting the legal requirements. This inspection took place on 26 January 2016. The inspection was unannounced. We checked that they had followed their plan and to confirm that they now met legal requirements. We found that the provider now met the legal requirements.

Holmwood Care Centre provides accommodation and nursing care for up to 60 older people some of who may be living with dementia. There were 51 people who were living at the home on the day of our visit.

The home is purpose built and is arranged over three floors. The ground floor provides support for those with residential care needs, one of these units specialises in supporting people who are living with dementia. The top two floors provide nursing care, of which, one unit specialises in nursing care for people living with dementia. The inspection team made checks in all areas of the home.

There was a registered manager in place at the time of our inspection; however the registered manager was not available on the day of our inspection. 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 lived in a safe environment as staff knew how to protect people from harm. We found that staff recognised signs of abuse and knew how to report this. Staff made sure risk assessments were in place and took actions to minimise risks without taking away people’s right to make decisions.

There were not always sufficient staff on duty to meet people’s needs who lived with dementia. It was recognised by the provider that this was an area to be addressed. People who lived in other areas of the home told us that staff helped them when they needed assistance. The deputy manager was hands-on and worked with the staff to assist them in reviewing staffing levels. The deputy manager had planned rotas to assist with the appropriate deployment of staff throughout the home. People’s medicines were administered and managed in a safe way.

People received care and support that was in-line with their needs and preferences. Staff provided people’s care in-line with their consent and agreement. Staff understood and recognised the importance of this. We found people were supported to eat a healthy balanced diet and with enough fluids to keep them healthy. We found that people had access to healthcare professionals, such as their doctor when they required them.

Some people told us that staff treated them kindly, with dignity and their privacy was respected. However three people we spoke with told us that some staff were not always kind towards them. One person told us they felt frightened when staff shouted in the corridors at night. The compliance manager and deputy manager were aware of some staff behaviours and had taken action to address this with the individual staff members. They told us that they would speak with the people who had raised concerns to establish if this was continued staff behaviour so further action could be taken.

People did not always receive care that was responsive to their individual needs and people were not involved in the review of their care. The provider had recognised this and had put plans in place to ensure people’s care was reviewed with them and their family members involved. The provider tol

This inspection took place on 5 May 2015 and was unannounced. The service provides care and support for up to 60 older people some of who may be living with dementia. On the day of our inspection there were 54 people who lived at the service.

There was 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 were protected from harm because staff knew how to protect them from abuse. We found that when staff reported abuse the registered manager took action. They worked with external agencies to ensure people were kept safe from harm. The provider had learnt from incidents and measures were put in place to reduce the likelihood of these incidents from happening again.

People’s individual risks were assessed and monitored. Where action was required to keep people safe from risk, staff were aware of this and what steps were to be taken to reduce the risk.

However, our findings from this inspection identified that there were insufficient staff to meet people’s needs. People did not receive care, treatment and support that was individual to them. We found that people received care and support based on staff’s requirement rather than the person’s needs. For example, we found three people were distressed and they told us they were frustrated. These people were assisted with getting up, washed and dressed twenty minutes before lunch was being served.

We found that because of staffing levels within the home, some people did not receive their medicines in a timely way, with some people receiving their morning medication 30 minutes before lunch time. The times people received their medication was not recorded to ensure people received their medicines with sufficient time’s in-between doses. However, we found the storage and management of medicines was done so in a safe way.

People who we spoke with felt that staff were knowledgeable about how to care for them. Staff told us they received training and this benefitted them in their roles. For example, staff knew why a person who was at risk of dehydration needed their fluid intake to be monitored and recorded. They used this information to ensure the person was drinking enough fluids to keep them healthy.

We found that people and where necessary, their family members, were sought for their consent in line with their care. We found these wishes were respected by staff and staff recognised the importance of this. All staff we spoke with were aware of people’s human rights and how this could be affected for people who may lack capacity. We saw that mental capacity assessments had been carried out where people were not able to make decisions themselves. We found that families were involved in making best interest decisions about the person’s care. However, we found that while the provider recognised that some people had their freedom restricted; this was not done so in a legal way. As the provider had not submitted the applications to the supervisory body in order to gain the correct permission.

We found people were supported with enough food and fluid to keep them healthy. We found that people had access to healthcare professionals, such as optician, dentist and their doctor when they required them.

People and relatives told us they felt listened to and were an active part in developing their care. However we found this was not always the case. People’s views and decisions they had made about their care were not always listened and acted upon. For example, people were not able to have a bath or shower when or as often as they would have liked. People told us that they would have to “book a bath” so that staff were available. One person told us that prior to coming to live in the home they would bathe every day, and now they were only able to bathe once a fortnight. During our inspection we found the communal bathrooms were used as storage areas for equipment and some baths were dusty. Staff told us that nobody had had a bath that day, but did not know why.

People did tell us that staff treated them kindly, with dignity and respect. People told us that staff respected their privacy, for example, staff would knock on their door and wait for a reply before entering. We saw staff interacting with people and they did so in a kind, caring and sensitive manner.

We found that the decision’s people had made about their care and support were not always met in a responsive way. Some people had to wait to be assisted to the toilet; others were required to wait to receive personal care in the morning while other people received their morning medication half an hour before lunch time. This was not personal to the individual’s choice and did not reflect their wishes.

We found that people knew how to complain and felt comfortable to do this. Where the provider had received complaints, these had been responded to.

The provider did not always demonstrate clear leadership. Staff were not always supported to carry out their roles and responsibilities effectively, which meant that people’s care was sometimes compromised. We also found that lack of communication hindered the effective and responsiveness of the care provided to people.

Our findings did not reflect the provider’s findings, which were largely task orientated roles, such as cleaning schedules. Where shortfalls were identified, effective systems were not always in place to ensure that lessons were learnt and used to improve staff practice.

We found three breaches of the Health and Social Care Act (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.

Holmwood provides care for older people. At the last inspection we found that the provider was not meeting the essential standards relating to care and welfare, safeguarding people, monitoring the quality of their service and records. This inspection found that improvements had been made in all of these areas.

We spoke with the registered manager, seven people who used the service, seven staff and one visitor.

People we spoke with were complimentary about the care and support that they received. One person said: "The staff look after me and are very friendly”. We found that proper steps had been taken to ensure that individualised care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare.

Robust arrangements were in place to ensure people were safeguarded from the risk of harm. One person said: "I am definitely safe here".

Staff had been recruited in an appropriate way and checks had been undertaken to ensure that they were suitable to care for vulnerable people.

A system of audits had been put in place and accurate records of care were maintained to ensure that people were not placed at risk of receiving inappropriate care.

We inspected Holmwood in April 2012 and found that they were not compliant with six regulations. The provider sent us an action plan following the inspection. This told us what they were going to do, how and by when to make sure that they became compliant with this regulation. This inspection was done to see what progress the service had made since our inspection in April 2012.

A new manager designate had been appointed and started in August 2012.

We found that the provider had made progress towards becoming compliant with the regulations since our last inspections in April, June and July 2012. People were being supported to make choices about their care and were receiving care in a timely manner according to their individual preferences. We saw that attention had been given to people's personal care, so helping to promote their self esteem. People told us the care was, “Fine”, “Good”, “All very positive so far”. The provider had maintained sufficient staffing levels at the home since July 2012 to meet the needs of the people who used the service.

Further improvement was still needed in identified areas in order to become fully compliant with the regulations. The provider needed to make sure that systems to assess and monitor the quality of the services provided were more thorough, as people were not being protected from the risk of receiving inappropriate care and treatment.

When we visited the service we met some people who lived there and also spoke to a relative. People told us they receive good care. They told us they are “really well looked after” and “could not have better staff”. They told us if they had any concerns about the care, they speak to the staff on duty who address it straight away. People told us the staff were nice and kind and “speak to you nicely”. They also told us there were sometimes too many agency staff on duty and these staff do not know the home like the regular staff.

People showed us a copy of the home’s activity programme for May which they had been given so that they are able to make choices about how and where they spend their time.

When we visited Holmwood Care Centre we found that many people had been treated with respect and their dignity and choice had been considered by staff, although there were occasions for a few people when their choice had not been respected and supported by staff.

We spoke with people who used the service which included two relatives. One person told us they liked being at the home and staff cared for them well. Another person said that you “can’t grumble at the care”. Two relatives said they were “very happy with the care their mum receives at the home”. “She (the service user) is happy here”.

During this visit, we looked at care plans and pathway tracked the care for four people. Pathway tracking looks at the experiences of a sample of people who use a service. This is done by following a person’s route through the service to see if their needs were being met. This visit found that care was not being assessed, planned and delivered in a person centred way to make sure that people had not been placed at risk of unacceptable harm.

We found that people who used the service may not be safeguarded from the risk of abuse.

We found that some people’s health and welfare needs were not being met in a timely way and according to their individual preferences. There were not enough suitably qualified staff on duty to safeguard the health and welfare of the people who used the service.

Staff had not received appropriate training, supervision and appraisal to make sure that people who used the service received an appropriate standard of care to safeguard them from any unacceptable risk of harm.

Systems to assess and monitor the quality of the services provided needed to be more thorough, as people were not being protected from the risk of inappropriate care and treatment.

When we visited the service we spoke with people who used the service. We asked people about their experience of the care at the home and they told us, it’s ‘alright’, very comfortable’. ‘I get all the help I need’. ‘I like to do things for myself’. We saw that people were neatly dressed in clean clothes and had clean glasses, hair and nails, indicating that staff knew the importance of helping people look their best.

We saw that staff interacted with people who used the service in a friendly, courteous and respectful manner at all times. People told us that the staff ‘are wonderful, they are very good’, ‘very friendly and helpful’. People told us that the staff speak nicely to them and listen to them and respect their privacy and dignity when washing and dressing them. We saw that people had access to a call bell to call for assistance when needed.

People told us they had a choice of food, although it was ‘not a wide choice’, which was ‘quite good’ and they had ‘no complaints’. People told us they had enough to eat and were not hungry.

We found that people may be placed at risk of receiving inappropriate care and support as a result of poor care planning and lack of communication within the service.

We found that systems for assessing and monitoring the quality of the services provided needed to be more thorough, as people were not currently being protected from the risk of inappropriate or unsafe care and treatment.

As part of our inspection at Holmwood we spoke with eight people who lived at the home. We also spoke with the manager, two nurses and three members of the care staff. We spent time with these people and relatives of two people. These people were able to tell us about people’s care and life at the home. At the time of our inspection 51 people were using the service.

We observed the care people received to meet their different needs over the course of the inspection. We also looked at a sample of care plans for three people who lived at the home and various management records. These records were used to review, monitor the quality of care and support that people received.

The manager at Holmwood had submitted an application for registered manager status to the Care Quality Commission (CQC). A registered manager is a person who has registered with the Care Quality Commission to manage the service and shares the legal responsibility for meeting the requirements of the law with the provider. We were due to hold an interview with the manager shortly after this inspection in order to assess whether registration would be approved.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information 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?

This is a summary of what we found-

Is the service safe?

We saw that people who used the service felt safe at Holmwood. We saw that staff were kind and friendly towards people and provided the care and support they needed. However at times staff did not answer call bells promptly and staff were not always available.

People were usually involved in day to day decisions and could make choices about what support they needed.

We found that risk assessments were usually in place to ensure that people were not placed at risk of inappropriate care and support.

Systems were in place to manage people’s medicines. These were not always sufficiently safe to ensure that people had received medicines and treatments in line with instructions.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. The provider had policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS). We found that the manager had knowledge of DoLS and was making some applications due to having some locked doors which potentially restricted people’s movement around the home.

Is the service effective?

People's health and care needs were assessed and care and treatment was planned in line with their individual needs. However, Care plans were not always effective in recognising people needs. For example, people’s care records were not always fully completed or up to date and did not always match their individual care needs. We were assured that improvements would be made to ensure that people were safe and received appropriate care and support.

We found from our observations and from speaking with staff that they generally had a good understanding of people's care and support needs.

Is the service caring?

We saw that staff treated people kindly. We saw staff interactions were supportive and usually respectful. Staff assisted people sensitively, whilst at the same time promoting their independence as much as possible. We saw that staff supported people and provided comfort and reassurance and gave people time to respond. One person who used the service told us, “No exceptions. The care is very good. Nothing is too much trouble for them (the staff)”.

We saw that staff respected people’s choices and they helped people to promote their own independence. We found that people were able to make choices about their drink although choice around their main meal was limited.

Is the service responsive?

The manager had worked with other health care professionals and other services to ensure that people received the appropriate level of care they needed.

People who used the service confirmed that they received help and support from health care professionals when required such as doctors, dentist and chiropodists.

We found that people were confident that any issues they had would be responded to in a timely way.

People who used the service confirmed that they received help and support from health care professionals when required such as doctors, dentist and chiropodists.

Is the service well led?

The quality of the service provided had been regularly assessed and monitored by the manager and the provider. We saw that the systems in place had identified some shortfalls and the actions to be taken to improve the service provided.

Staff told us they received supervision and training. We found that the manager was aware of gaps in some people’s training requirements. Staff felt supported by the registered manager.