This unannounced comprehensive inspection took place on 25 September 2018 and the inspector returned on 26 September to conclude the visit. This meant the staff at Howdon Care Centre did not know we would be arriving on the first day.

Howdon Care Centre is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. At the time of our inspection 59 people living with physical and mental health related conditions were using the service.

At the last inspection we identified five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, related to safe care and treatment, consent, complaints, staffing and good governance and one breach of the Care Quality Commission (Registration) Regulations 2009 in relation to unreported incidents of suspected neglect. We rated the service inadequate. Following the last inspection, we met with the provider to confirm what they would do and by when to improve the key questions safe, effective, caring, responsive and well-led to at least good. We asked them to complete an action plan and submit weekly updates, which they did. We imposed a condition on the provider’s registration to restrict them from admitting any new people into the home until we were satisfied the service was safe. At this inspection, we found improvements had been made at the service which ensured compliance with the fundamental standards.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures. We have also removed the restrictive condition on the provider’s registration.

A new registered manager was in post since our last inspection. A registered manager is a person who has registered with 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.

At the last inspection we issued the provider with a warning notice for their failure to ensure good governance of the service. The provider indicated in their action plan that the registered manager and staff at the home were now effectively completing daily, weekly and monthly checks on the quality and safety of the service. They told us there was robust oversight by a regional manager, the managing director and the chief operating officer. We found that these checks had consistently taken place since May 2018. The registered manager had identified issues and resolved them promptly. We considered the provider now had thorough oversight of the service.

Record keeping throughout the service had significantly improved. The provider now held a clear and accurate record of the care and treatment people received.

After the last inspection we issued the provider with a fixed penalty notice because they had failed to ensure that all serious incidents were reported to CQC as legally required. We saw this had now been addressed.

Accidents and incidents were recorded on a central system and information about an investigation and an outcome was available to us. The registered manager ensured all incidents were reported where appropriate to the necessary authorities. This improvement meant that the registered manager and provider could carry out proper audits to analyse the information and look for trends which in turn would reduce a repeat occurrence within the service and across

Howdon Care Centre 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. The home is divided into four units and has a large kitchen and laundry area. At the time of our inspection 59 people with physical and mental health related conditions were using the service.

This unannounced comprehensive inspection took place on 17, 18 and 19 April 2018. This meant that the provider, staff nor people who used the service knew we would be arriving. At the last focussed inspection in November 2017, we identified four breaches of regulations which related to safety, people’s nutritional needs, staffing and the governance of the service. We asked the provider to take action to make improvements. We found whilst improvements had been made to the care of people with nutritional needs, insufficient improvements had been made to the service to ensure compliance with all of the health and social care regulations.

This is the second consecutive time the service has required improvement. The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

A new care manager was in post who managed the service on a daily basis. They had been employed at the service for approximately three months. The care manager was in the process of applying to become the registered manager. 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 regional manager had only been assigned to oversee Howdon Care Centre four weeks prior to this inspection.

We undertook an observation around the home to look at the issues which had been highlighted to the provider at our last inspection. Whilst we found some action had been taken; we found the checks on the service were still not robust enough to ensure compliance with all of the regulations. Issues remained at the home which had either not been wholly addressed or had not been properly monitored to ensure that staff had complied with the tasks delegated to them.

The provider indicated in an action plan

This focused inspection of Howdon Care Centre took place on 21and 30 November 2017. It was an unannounced inspection which meant that the staff and registered provider did not know that we would be visiting.

We carried out an unannounced comprehensive inspection of this service on 30 November and 1 December 2016 and found the provider was meeting the fundamental standards of relevant regulations. At that time we rated Howdon Care Centre as ‘Good’ overall and ‘Good’ in all five domains. After that inspection we received concerns in relation to staff ability to support people who had compromised gag reflexes. As a result we undertook this focused inspection to look into those concerns. This report only covers our findings in relation to this topic. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Howdon Care Centre on our website at www.cqc.org,uk

Howdon Care Centre is a ‘care home’. People in care homes receive accommodation, nursing and personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. Howdon Care Centre accommodates up to 90 people across four separate units, each of which have separate adapted facilities. Two of the units specialise in providing care to people living with dementia and one provides general nursing care. At the time of this inspection 88 people were in receipt of care from the service.

The home has not had a registered manager since September 2017. A registered manager is a person who has registered with 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. The provider had recruited a new manager at the end of September 2017.

Although they had been reviewing the service and making changes we saw little evidence of good governance or leadership. We found the manager was not able to discuss confirm to us the needs of people who used the service or accurately described the layout of the service.

We found that there were insufficient staff employed and deployed at the service to ensure people’s needs were met. The provider used a dependency tool but this did not take into account the size and layout of the service, which was in effect four 20+ place homes. Thus staff were working in teams of three to five care staff with senior staff covering two units. We found staff were unable to meet people’s needs.

We identified a number of concerns around the management of health and safety risks such as appropriately supporting people who required adapted diets and individuals who were at risk of falls. The provider had been alerted to these concerns during recent safeguarding investigations. In response to this they had had organised a full range of training and supervision around supporting people who have compromised gag reflex to eat.

However, on the first day of the visit we observed staff not adhering to care plans for instance, giving people food that had not been fork-mashed, when they required their food to be of this consistency. Following the first day of the inspection the provider ensured action was taken to rectify this and the cooks sent adapted meals to units, which were identified for each person who required these meals. Also we found there were insufficient tables and chairs on each unit to ensure all of the people could eat in dining rooms and no adapted plates and cutlery were being used, which led to people struggling to consume their meal. Albeit drink dispensers were located in each lounge, these either did not have any glasses or people could not independently reach them. Staff’s ability to spend time in the lounges was very limited so people were not offered drinks other than at set ti

This inspection took place on 30 November and 1 December 2016 and was unannounced. A previous inspection on 4, 5 and 7 August 2015 found two breaches of regulations. These related to infection control and the need for consent. At this inspection we found action had been taken to address the concerns previously highlighted.

Howdon Care Centre is registered to provide accommodation with personal and nursing care for up to 90 people. At the time of the inspection there were 79 people using the service. The home was divided into four smaller units, some of which supported people living with dementia.

The home had a registered manager who had been registered since December 2014. 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 and relatives told us they felt safe at the home. Staff had received training in relation to safeguarding vulnerable adults. Any safeguarding matters had been recorded and reported appropriately to the local authority safeguarding team.

Checks on the safety of the home were undertaken to ensure that fire equipment and other safety issues were monitored. People had personal emergency evacuation plans to allow staff to support them appropriately in the event of a fire. Risks regarding people’s care needs were also assessed and reviewed.

Suitable recruitment procedures and checks were in place to ensure staff had the right skills to support people at the home. People told us there were sufficient staff deployed at the home to support their needs. Accidents and incidents were recorded and monitored to help identify any trends or concerns. We found medicines were appropriately managed, recorded and stored safely. The home was maintained in a clean and tidy manner. At the previous inspection we had noted equipment to support people’s personal care was not always available. At this inspection we saw there was plenty of wipes and personal care equipment available.

Staff said they had the right skills and experience to look after people. They confirmed they had access to a range of training and updating. The registered manager showed us the staff training system which indicated a high level on completion for a range of courses. Staff told us, and records confirmed regular supervision took place and that annual appraisals were undertaken.

The registered manager confirmed applications had been made to the local authority safeguarding adults team to ensure appropriate authorisation and safeguards were in place for those people who met the threshold for DoLS, in line with the MCA. We saw copies of applications still in progress and confirmation letters where DoLS applications had been approved.

At the previous inspection staff did not always understand the concept of assessing people’s capacity to make decisions or acting in people’s best interests. At this inspection we found action had been taken and, where necessary, best interests decisions had been undertaken and recorded.

People’s health and wellbeing was monitored, with ready access to general practitioners, dentists, opticians and other health professionals. Visiting health professionals told us staff were proactive in supporting people’s health needs.

People told us that overall they were happy with the food at the home. We observed meal times and saw food was generally of a good standard, looked appetising and was hot. Kitchen staff demonstrated knowledge of people’s individual dietary requirements. Changes had been made to the units supporting people with dementia to better support their needs and minimise distress.

People and their relatives told us they were happy with the care provided. We observed staff treated people patiently and appropriately. Staf

In this report the name of a registered manager appears who was not in post at the time of the inspection. Their name appears because they were still a registered manager on our register at the time.

We found medicines were handled safely, and people received them at the times they needed them.

The acting manager told us that they were in the process of fully auditing and updating all the care records for people who used the service. We found care records were up to date and the information they contained matched the care being delivered. Staff had a good knowledge of people's care plans and their individual needs. Staff told us and records confirmed that there had been one formal staff meeting since our last inspection. We saw that a range of items in relation to care and record keeping had been covered. There had been one meeting with relatives. One of the comments recorded as being made by a relative said, "were encouraged by the consistent leadership.”

We found that care plans were up to date and contained good detail. We were able to track people’s care through the records. We found that food and fluid intake were recorded in detail. The acting manager told us that each person using the service was allocated a trained nurse, or senior care, and two care staff as key workers. Nursing staff and key workers were responsible for maintaining accurate records.

Staff checked with people that they were happy with how they were being treated and offered them choices. One relative told us, “I was involved with the care plan and with the social worker and Swan Lodge.” One member of staff told us, "I ask people if they are happy with what I am doing and if not how they want things to be done differently.”

Most care plans were specific and contained detail about the care to be delivered. One person who used the service told us, “It’s generally ok in here. It’s very pleasant. I am quite happy." Some assessment information that would be used to inform care plans was not readily available. We found one instance where someone had not had access to the correct wound dressing for a number of days.

People were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place for the recording and handling of medicines.

Consistent levels of staffing were maintained to deliver the care required.

The provider had not monitored the quality of the service people received or undertaken audits of the care provided. Meetings with people who used the service or their relatives had not been held regularly.

We examined the case records of six people and found in some cases that care delivery records maintained within people’s rooms were incomplete.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of inspection. Their name appears because they were still a Registered Manager on our register at the time.

We looked at the environment in which people were cared for and the equipment available to support them in their daily lives.

We saw the ground floor accommodation had been fully refurbished, was bright, appropriately furnished and decorated. Bedrooms had new furniture and their en suite facilities had been refitted. One person we spoke with told us, “Oh yes, I like my room.”

Doors leading to the bathrooms and toilets had been painted a different colour to other rooms to help people identify these facilities. Lounges had new carpeting and in a small quiet room a library had been created for people who used the service.

We noted bathrooms contained modern easy access baths. Wet rooms with showers were clean with good access. One staff member told us, “The residents love the baths, they are absolutely fabulous."

We looked at the care records of four people who used the service. Care plans had been reviewed and, where necessary, rewritten to reflect people’s changing needs. Records for food and fluid intake and for positional changes were fully completed and up to date.

We spoke with eight people and two relatives to find out their opinions of the home.

We looked at four people's care plans. In particular we looked at moving and handling issues. We saw evidence that needs were assessed and care was planned and delivered in line with their plans. We observed the use of lifting belts to assist people who had difficulty in standing and did not view any unsafe practice in relation to lifting.

At the time of our inspection the lower floor of Swan Lodge was undergoing major refurbishment. We found there were no assessments to minimise risk from this work for people living there. We concluded people were not fully protected against the risks of unsafe or unsuitable premises.

We confirmed there was a staff training record. Staff told us they received regular supervision and that they had annual appraisals. We concluded staff received appropriate professional development.

We found some records were not complete. We saw the daily progress reports did not always reflect the care plan or the current concerns about people. Because the records did not reflect what was written in care plans or what we were told this created a risk that people may not receive the correct care.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time.

This inspection took place on 4, 5 and 7 August 2015 and was unannounced. This was the first inspection of Howdon Care Centre, under its current configuration. Previous inspections of Swan Lodge and Hunter Hall, the two homes combined to bring about Howdon Care Centre had identified concerns about the level of activities available to people living at the home.

Howdon Care Centre is registered to provide accommodation for up to 90 people. At the time of the inspection there were 63 people using the service, some of whom were living with dementia.

The home had a registered manager who had been registered since December 2014. 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.

The home did not have a good supply of equipment to support people with their personal care. We found there were no suitable wipes available and staff were providing personal care using either flannels or paper towels. We raised this issue with the registered manager who said suitable stocks of equipment were on order.

We found it was often difficult to locate staff and that areas of the home were sometime unobserved for periods. Staff and people using the service told us the home would benefit from more staff at times. The registered manager told us she had been granted permission to increase the number of care staff working on a day shift.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS). DoLS are part of the Mental Capacity Act 2005 (MCA). These safeguards aim to make sure people are looked after in a way that does not inappropriately restrict their freedom. The registered manager confirmed applications had been made to the local authority safeguarding adults team to ensure appropriate authorisation and safeguards were in place for those people who met the threshold for DoLS, in line with the MCA. We saw copies of applications still in progress and confirmation letters where DoLS applications had been approved.

Staff did not always understand the concept of assessing people’s capacity to make decisions or acting in people’s best interests. We found some people had bed rails in use, to stop them falling out of bed, and lap belts to support them in chairs without proper assessment and consideration of whether this was in their best interests, as laid out in the MCA. One person was potentially receiving medicines combined with their food, without proper assessment and consideration.

People and their relatives told us they felt safe at the home. Staff were aware of the need to protect people from abuse. There told us they had received training in relation to safeguarding adults and were able to describe the action they would take if they had any concerns. They told us they would report any concerns to the registered manager, the nurse in charge or the local authority safeguarding adult’s team. The registered provider monitored and reviewed accident and incidents.

Suitable recruitment procedures and checks were in place to ensure staff had the right skills to support people at the home. We found medicines were appropriately managed, recorded and stored safely.

Staff felt they had the right skills and experience to look after people. They confirmed they had access to a range of training and updating. The registered manager showed us the new staff training system that had recently been introduced by the provider and said it would help to monitor individual’s training. Staff told us, and records confirmed regular supervision took place and that they received annual appraisals.

People’s comments on the food were variable. Some people indicated the food was good whilst others felt there were areas that could be improved. We observed meal times and saw food was generally of a good standard, looked appetising and was hot. Kitchen staff demonstrated knowledge of people’s individual dietary requirements and current guidance on nutrition. We noted people on special diets did not always get the same choice as those accessing the home’s standard menu.

People and their relatives told us they were happy with the care provided. We observed staff treated people patiently and appropriately. Staff were able to demonstrate an understanding of people’s particular needs. People’s health and wellbeing was monitored, with ready access to general practitioners, dentists, opticians and other health professionals. We observed staff supported people in a caring and appropriate manner and with dignity and respect.

Care plans reflected people’s individual needs and were reviewed to reflect changes in people’s care. We saw a range of activities were offered, including exercise classes and other events, such as a gentleman’s club and discussions groups. Some people said they would like more trips out and the registered manager told us the home now had access to a minibus.

People told us they were aware of the complaints process and could raise issues if they had concerns. The registered manager told us there had been two recent formal complaints and demonstrated how these were being dealt with.

The registered manager undertook regular checks on people’s care and the environment of the home. She confirmed the regional manager also carried out regular audits. Staff told us the recent changes at the home, including the merging of the homes and supporting the closure of another home close by had been difficult at times, but things were now settling down. Staff felt the registered manager was accessible and supportive. There were regular meetings with staff and relatives of people who used the service, to allow them to comment on the running of the home. A new electronic feedback system, recently installed at the home, indicated a high level of satisfaction from relatives and people using the service.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This related to safe care and treatment and the need for consent.