The inspection was unannounced and took place on 28 February 2017. We arranged with the registered manager to return on the 3 March 3017 to finish our inspection.

The home is registered to provide accommodation and personal care, for a maximum of 32 people. There were 25 people living at the home on the day of the inspection.

At the last inspection on 22 and 24 July 2015 the service was rated as good. Since the last inspection the home has changed from providing rehabilitation services to providing longer term residential care. There was a registered manager in place at the time 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 told us they felt safe and well cared for. Staff were able to demonstrate they had sufficient knowledge and skills to carry out their roles effectively and to ensure people who used the service were safe. People told us staff were available and responded when they needed care.

People were cared for by staff who were trained in recognising and understanding how to report potential abuse. Staff knew how to raise any concerns about people’s safety and shared information so that people’s safety needs were met. People were supported by staff to have their medicines when they needed them.

The registered manager was aware of their responsibilities in regard to the Deprivation of Liberty Safeguards (DoLS) and had submitted applications where they had assessed that people were potentially receiving care that restricted their liberty. Staff sought people’s consent before providing care and provided choices so people could choose the support they received.

People told us they enjoyed meals times and were very positive about the choice and quality of the food they received. They told us they were offered a choice of drinks throughout the day. People were supported to access health care professionals and staff responded to the advice received in providing care to people.

People told us staff were caring and we saw people were comfortable around staff providing care. Relatives told us people had developed good relationships with staff and they felt welcomed into the home whenever they visited. Relatives said people’s privacy and dignity was maintained and our observations supported what relatives told us.

People we spoke with told us they got the care and support they wanted and they chose how they spent their day. Staff told us that activities could be improved to support people’s interests and the registered manager was in the process of planning new activities to make improvements.

People were involved in making day to day decisions about their care and said staff listened to them and they felt confident they could raise any issues should the need arise.

Staff said that the service had been through a period of change. They acknowledged recent improvements had been made but said further improvements were needed in activities. People, relatives and staff spoke positively of the management team and of the team work of the staff team.

People and relatives said the registered manager was approachable. Staff spoke highly of the registered manager and staff said they were supported through team meetings and training to provide care and support in line with people needs and wishes. The quality of service provision and care was monitored and actions taken where required to improve people’s experience of living at the home.

People and relatives were positive about the care and support they received and the service as a whole.

We inspected Howbury House on the 17 February 2015. Howbury House provides intermediate care beds to people to support admission prevention and timely discharges for approximately up to six weeks. They also provide permanent and respite services for people with dementia related illnesses. At the time of our 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.

We found that people were kept safe by staff who knew how to protect people. We found that people were cared for in a supportive way that did not restrict their freedom. The provider of Howbury House had ensured the building was safe for people who had poor mobility or for those that lived with dementia. There were sufficient staff on duty to meet people’s needs.

People’s medication was stored and managed in a way that kept people safe. People received their medication at the correct times by staff who were trained to do so.

People were cared for by staff who had the knowledge and skills to meet peoples care needs. People had access to healthcare professionals and were supported to appointments, such as the doctors and physiotherapists and occupational therapists.

People we spoke with were complimentary about the food and their dining experience. Staff knew people’s likes and dislikes and respected their wishes. We observed people received regular drinks and staff supported those who needed assistance.

People told us that all the staff were caring and that staff were respectful and talked to them calmly. Some people who lived at Howbury House were unable to tell us verbally if the staff were kind and caring however we observed that people were relaxed and calm in the home. People told us that they were listened to and an active part in the planning and treatment of their care. We saw care staff spoke kindly to people and maintained their dignity when providing assistance. People were supported to remain independent and received assistance when they needed it.

We found that the service was responsive towards people’s social needs. Staff showed us how they used people’s history and past experiences to develop activities that people enjoyed and that they were personalised to their choice. Staff knew people’s likes and dislikes and respected their wishes.

People and relatives told us they found staff and the registered manager approachable and told us they could raise any complaints or concerns should they need to. Everyone we spoke with told us that they had never needed to complain or had anything to complain about.

Through regular meetings we found that the registered manager promoted a positive culture, in which they invited people to talk with them about any concerns they may have.

We found the registered manager had systems in place to ensure that the quality of the care was monitored. Checks in areas such as medication and environment were carried out and completed monthly. Where there were any actions following these checks they were followed up and improvements were made.

An adult social care inspector carried out this inspection. As part of the inspection we spoke with six people who used the service individually, seven people in small groups and one visitor. We spoke with the registered manager, two senior staff, four care staff and one health professional. We also reviewed the records relating to the management of the home which included six care records, six staff personnel records, policies and procedures, and minutes of meetings.

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

Is the service safe?

People told us that they felt safe. Risk assessments were well completed and actions to minimise risks identified were reflected in care plans. Risk assessments balanced risk with the rights of people to choice and independence.

The provider had appropriate systems and processes in place with regard to safeguarding adults and implementing the Mental Capacity Act 2005. Staff had received training and were clear about their role and responsibilities.

Records were kept securely and were available to read. Improvements were needed however, to ensure all records are accurately maintained and kept up to date. We have asked the provider to make some improvements in relation to record keeping at the service.

Is the service effective?

People we spoke with told us that the service they received helped them to regain their independence and confidence. People, who required it, received regular physiotherapy and occupational therapy. Staff demonstrated that they understood the care needs of the people they were caring for.

Staff had access to a range of training relevant to their role. Policies and procedures were appropriate, up to date, and reflected current research and guidance. Staff had access to information about meeting the needs of people from different cultures and faiths.

Is the service caring?

People told us that the staff were kind and caring. We observed staff treating people in a friendly and caring way. One person told us, "I couldn't wish for better care.” People told us that staff were always quick to respond to them if they needed assistance.

People on the dementia respite care unit were cared for in a calm atmosphere. Art and pictures were used to help people to find their way around the unit and to stimulate memories.

Is the service responsive?

People's needs were assessed prior to them being admitted. People told us that they had been involved in developing their care plan. One person told us, "The staff sat down with me when I first came. They went through what I could expect and asked me about my wishes.”

We saw evidence of a range of activities that had taken place. Some people told us that they were not aware of all the activities that were available to them. We brought this to the attention of the registered manager.

Is the service well led?

Staff we spoke with told us that they were well supported by the registered manager and senior staff.

People were invited to raise issues about the service with a specific member of staff and also at 'Have Your Say' meetings. People told us they would be comfortable raising issues with the registered manager. People told us they were confident any issues raised would be acted upon.

Regular audits were undertaken to monitor the quality of the service. Generally the audits were robust. However, the care plan audit was not as detailed as it should be. The registered manager showed us a new improved audit process which was about to be introduced.

People who used the service and staff were clear about the complaints process. Complaints that had been received by the provider had been investigated and responded to appropriately. Lessons learnt from incidents, feedback, and complaints and any subsequent actions were discussed at regular staff meetings.

The service provided intermediate care for older people and respite care for people with dementia. During this inspection we spoke with 10 people who used the service, the registered manager, the deputy manager and four staff. People we spoke with were complimentary about the care and support that they received. People told us that Howbury House was: “A superb place. May it never change. Everybody is so kind”. “Don’t ever change it. It should have top marks”.

People told us that they felt involved in any decisions that needed to be made about their care and these were made in their best interests. 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.

We found that medicines were prescribed and given to people appropriately that ensured they were managed safely. This meant that people received their medicines as prescribed.

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

We found that any comments and complaints people made had been responded to appropriately and ensured that people were listened to.

When we visited Howbury House we spoke with several people who used the service. We found that people were able to express their views and had been involved in making decisions about their care and treatment. People told us that the staff always respected their privacy and dignity when they assisted them with personal care.

We found that care and treatment had been planned and delivered in a way that met with the essential standards. People told us the service was “excellent”. “If you want a shower you have only got to ask”. You “can’t grumble at all” and “It’s a marvellous place”. They told us that if you rang for assistance, “staff come fairly to quite quickly when needed, they don’t keep us waiting long”.

We found that people who used the service were protected from the risk of abuse. People who used the service told us they felt safe and they were aware of how to complain.

People told us that they received a good standard of care from the staff who worked for the service. They told us that staff were “very nice, very helpful and kind” and they “speak nicely to us”. We found that people were cared for by staff that were supported to deliver care and treatment safely and to an appropriate standard.

People who used the service were asked for their views about the care and treatment provided. We found that the service had an audit system in place for monitoring the quality of the service.

Records showed that people had given written consent to any treatment they needed at Howbury House. We found that the two records that we looked at contained missing or incomplete information. This meant that the care records did not accurately reflect their care needs. This may place them at risk of receiving inaccurate care.