This unannounced inspection took place on 22 May 2018.

At the last inspection carried out in 2015, we found that the provider was rated ‘Good’ in all areas except for well-led, which was rated, ‘Requires improvement’. This was because they had not submitted notifications when required. At this inspection we found that the registered manager had sent us notifications as required by regulation.

Homestead House is a care home providing personal care to up to 21 people, some living with dementia. There is one shared room. Some rooms have en-suite toilet facilities and there are communal bathroom facilities available. At the time of our inspection there were 17 people living in the home.

Homestead 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.

There was 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.

Risks to people were not always fully identified, assessed and mitigated. This included risks associated with falls and people’s conditions, as well as the management of some prescribed items. ‘As required’ (PRN) medicines were not always planned for and recorded appropriately. Not all of the staff had a thorough knowledge of safeguarding.

People did not always receive care that was in line with their individual preferences and these were not always recorded. There were some activities on offer for people, but these were not organised and planned in line with people’s preferences.

The auditing systems in the home did not always identify areas where further improvement was needed. These included medicines audits and audits for overseeing the content of care plans.

Medicines were stored securely at a safe temperature and were administered by trained staff. There were systems in place to keep the environment safe for people, however improvements were needed to the systems to mitigate risks associated with legionella.

There were enough staff to meet people’s needs and recruitment procedures which contributed to keeping people safe. Staff had training in areas relevant to their roles and new staff shadowed more experienced staff.

There was not a thorough understanding of the Mental Capacity Act (MCA), as mental capacity assessments were not always decision-specific, and best interests’ decisions had not been recorded.

People were supported with meals and drinks, however they were not always supported fully in line with their care plan. Meals were not always nutritionally balanced, and people did not always have access to a drink. However, people were offered drinks regularly throughout the day.

People’s needs were assessed prior to moving into the home. People had care plans which guided staff on how to meet their needs, although these were not always detailed with individual preferences and updated.

Staff knew people and their needs well, and adapted their communication to support people living with dementia.

Staff supported people to maintain their independence as much as possible, and supported their privacy and dignity.

People and their families knew how to complain and felt comfortable to raise any concerns with staff. Staff involved people in their care.

There was training in end of life care planned for staff, and the registered manager discussed people’s wishes with them, when they felt comfortable to do so.

There was good leadership in place and staff worked well as a team. People were asked for their views on the service.

The inspection took place on 27 October 2015 and was unannounced.

Homestead House provides care and support for up to 19 older people, some of whom may be living with dementia. The home is over two floors and some rooms are shared. At the time of our inspection there were 19 people living there.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People were supported by staff who had undergone appropriate recruitment checks to ensure they were safe to work in health and social care. Staff were well trained, competent and passionate in their roles. There were consistently enough staff to meet people’s needs and keep them safe.

People were protected from harm by staff who understood the importance of preventing, recognising and reporting potential signs of abuse. People received their medicines as prescribed and the service managed medicines safely and appropriately.

Staff had received regular training and the service had plans in place to further develop staff’s skills and knowledge. Staff demonstrated the skills they had learnt. New staff had undergone an induction which included completion of the care certificate.

People benefitted from a staff team who were motivated, worked well as a team and felt supported. Staff were happy in their work and supported people with kindness, compassion and thoughtfulness. Staff had good knowledge of the people they supported and they maintained people’s independence and dignity whilst encouraging choice. Staff supported people in their likes and dislikes and people were fully involved in decisions around the care and support they received.

The Care Quality Commission is required to monitor the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS) and report on what we find. People were not being deprived of their liberty unlawfully. Staff understood about people’s capacity to consent to care and had a good understanding of the MCA and DoLS which they put into practice. The service had made appropriate applications to the local authority.

People’s plans of care were developed around the individual with involvement of those important to them. Care plans gave staff full and clear guidance on how people wished to be supported. People’s changing needs were regularly assessed.

Although the service did not consistently meet individual needs in relation to their hobbies and interests, the service provided regular interaction which was warm and meaningful.

The service had an open, supportive and transparent culture and people felt they were listened to. People’s views and feedback was encouraged in order to improve and develop the service. Suggestions were listened to and actioned where appropriate. People felt staff were approachable and felt confident in raising concerns. The provider had effective quality monitoring systems in place that contributed to the development of the service. However, the service had not consistently reported important events that affect people’s safety.

We carried out two inspections at Homestead House on 31 January 2013 and 24/26 June 2013. At the first inspection concerns had been identified on how people living in this home were involved in their day to day lives. At the second inspection, although improvements had been found the provider still had some improvements to make to ensure the home was compliant and meeting all the needs required.

The provider sent us an action plan on 9 August 2013 telling us that all the actions required at the last inspection would be completed by the end of August 2013. At the inspection of 1 November 2013 we found that the actions for improvement had been carried out as stated.

We found in the three care plans looked through that records had improved. Risk assessments held more detail and had been dated and signed. People were receiving care that was suitable and safe for them.

Improvements had been made to all of the meals on offer. Menus had been updated with more variety. Choices of nutritional meals were evident and people had pictorial menus to aid their decision making. Food and fluid consumed was monitored and people were assisted with supplement foods when required.

Staff support had improved with more planned supervision sessions and annual appraisals taking place. People using the service were assisted with their care needs by staff who were trained and supported to do the job required.

Improvements found in the system used to measure the quality of the service ensured that any concerns or improvements were carried out appropriately.

We assessed compliance with Outcome 9 following our inspection of June 2013 when we found concerns relating to how the service managed people’s medicines. Since then managers have developed an action plan to help make improvements. During this inspection, our checks found medicines were given to people correctly. Records about medicines were complete and accurate. Improvements had been made to the arrangements for the storage of medicines. We noted some improvements had been made to the information available to help make sure medicines were being safely administered to people.

We visited the service to assess compliance with the Warning Notice issued following our inspection 22 February 2013 when we found major concerns relating to how the service managed people’s medicines. During this inspection we noted improvements but identified ongoing concerns relating to the security of medicines which still placed people living at the service at risk. Whilst we noted improvements in relation to record-keeping of medicines, we identified a further discrepancy which we asked the provider to investigate. We assessed training records and are awaiting further confirmation that members of staff have received recent training to ensure they are competent to handle and administer people’s medicines.

We visited on 22 February 2013 to look at the medication administration practices of the service. However, during the course of the inspection we identified concerns in other areas.

We found that the service was not following safe procedures for administering and storing medicines. The door to the medications room was left open and accessible and the medication cabinet within the room was also left open. We found numerous discrepancies in the records relating to medications. The temperature of the medications fridge was found to be consistently above what is recommended.

We found that people’s care, welfare and safety was at risk through inaccurate or absent care planning and risk assessing. We found that for one person, who was at risk of falls, there was no planning to minimise this risk. We were told by a visiting health professional that many people had developed a new pressure sore in the weeks prior to inspection. However, we found no care planning about the prevention of pressure sores in care records.

We found that there were not enough staff to meet the care needs of those using the service. Two visiting health professionals and three members of care staff told us that they felt the staffing level was not sufficient to meet people’s needs.

Staff told us that they had to work long shifts, and that they felt this was unsafe and could lead to mistakes. This was corroborated by the contents of a safeguarding concern received in February 2013.

We spoke with four people using the service who were very complimentary about the care they received. They told us that staff were kind to them and looked after them. One person told us, "I like the girls here, all my clothes are clean and I get clean clothes every day." Another person told us, "I'm very happy here." One other person told us, "It's nice here."

We found that people using the service had an assessment of their needs and how their needs would be met were set out in a plan of care. However, we found that people’s preferences were not taken into account when planning their care.

We found that people using the service were not given a choice of food and hydration at meal times, however, we saw people being assisted to eat their meal with dignity.

We found that people using the service or their relatives were not given the opportunity to give feedback on the service or suggest improvements regularly. The provider was unable to produce records of any feedback sought after 2010.

On the day of our visit on 27 January 2012 we were told that staff do help when needed. People told us that staff are good and that they know how to help. At this visit we saw staff providing support with due consideration for dignity and choice.

People were happy with the care they received and people liked the meals, only one person said the food was ‘alright.' People showed us the personal items they had brought into the home and said that staff worked hard to make certain they had what they needed.

People confirmed that staff are available when needed and would always listen and help if needed

We found that there were still brief or incomplete life histories and a lack of documented preferences for people living with dementia. One person we spoke with told us, "I like baking; I used to bake cakes for all the family every Christmas". However, none of these details were documented in the care planning.

We found that the provider was not following published guidance with regard to assessing people's mental capacity and that there were inconsistencies in some care planning.

We found that people were not getting a choice of food at meal times. One person told us, “No, I just get what comes” when asked if they chose what they were having for their meal.

We found that the staffing level had improved, and staff felt better supported. Some staff told us they had supervision with their manager, but we could not view records of this.

We found that the provider had put in place regular audits, but that these were not effective and were not picking up issues. We found that the provider had paid no regard to comments and views expressed by people using the service.

We identified failures including numerical discrepancies in medicines, gaps in records, inadequate storage of medicines, inadequate handling of medicines with short shelf lives. We were concerned that some members of staff may still not have had recent medicines training which could affect their competency to handle and administer people’s medicines.