About the service: Howgate House is a care home which provides personal and nursing care to people, mainly older people and people living with dementia. At the time of our inspection there were 47 people using the service.

People’s experience of using this service:

There were not always enough suitable qualified staff on duty. There were times when people were left for long periods of time with little or no social interactions. A relative told us they thought the service was short staffed.

Staff were kind and caring however some lacked awareness of people’s cultural needs.

Risks to people’s safety and welfare were not always managed properly.

People’s medicines, particularly cream and lotions were not always well managed.

Staff understood how to recognise and report abuse. The required checks were done before new staff started work and this helped to protect people from the risk of harm.

People were offered a choice of food and drink. However, people who were at risk of poor nutrition did not always get the right support to meet their dietary needs.

Staff received training and told us they felt supported by the new manager and deputy manager.

Peoples care records were not always up to date and accurate. This created a risk people would not receive the right care and support.

Decisions made in people’s best interests were not always clearly recorded.

The service worked with other health care professionals. However, we found some people may have benefitted from more involvement by external health care professionals.

The new manager was clearly committed to making improvements to the service. They had started to carry out audits and checks. They had identified and started work on areas which needed improvement.

The provider was not able to demonstrate they learned lessons when things went wrong. Similarly, they were not able to demonstrate they acted on people’s feedback to make improvements to the service.

Rating at last inspection: The rating at the last inspection was ‘requires improvement.” The report was published on 8 September 2018. In September 2017 the service was rated ‘requires improvement’ overall. Prior to that the service was rated ‘inadequate’ in March 2017 and ‘good’ in July 2015.

Why we inspected: The inspection was brought forward because we received information of concern about the standards of care, leadership and management and staffing.

Enforcement: At the last inspection we found the provider was in breach of three regulations of Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. During this inspection we found the provider remained in breach of these regulations and we identified a further three breaches of regulations. 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.

Follow up: The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

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 improv

The inspection was unannounced and took place on 17 and 26 July 2018.

Howgate 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.

Howgate House accommodates a maximum of 63 people in one building over three floors.

There are communal rooms on two floors and there is an accessible outside area. The building has access for people with disabilities and there is a passenger lift to all floors. At the time of our inspection there were 53 people living at the home.

At the last inspection in September 2017 we rated the service ‘requires improvement’ overall. There were no breaches of regulations. During this inspection we found the provider had not sustained and built on the improvements they had made and we rated the service ‘requires improvement’ overall.

There was no registered manager in post when we carried out this 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.

A peripatetic manager was in charge of the service at the time of our inspection. People who used the service, relatives and staff spoke positively about the peripatetic manager. However, some concerns were expressed about what would happen when they were no longer based at Howgate House.

People told us they felt safe. However, we found there were not always enough suitably qualified staff on duty. The provider was not working to their planned staffing levels. There were occasions when agency nurses were in charge of the home without management support or the support of qualified care workers, known as care practitioners.

Staff received training on safe working practices. However, we found staff had not received training related to the particular needs of people who used the service.

Staff knew how to recognise and report any concerns about people's safety and welfare. The required checks on new staff were done before they started work and this helped to protect people.

We found the service was acting in people’s best interests but this was not always reflected in the records.

People were offered a choice of food and drinks and snacks were available throughout the day. We found improvements were needed to the way people with more complex needs were supported to express their choices at meal times.

People’s needs were assessed before they moved in. People were supported to access the full range of NHS services which helped to ensure their healthcare were met needs.

The home was clean and well maintained. However, we found staff on the first floor were hand washing crockery and cutlery and this was not in line with good infection control practices.

Staff supported people to maintain their independence. However, there was a lack of dementia friendly signage to help people find their way around the home.

People’s medicines were managed safely.

Accidents and incidents were recorded. The peripatetic manager was putting processes in place to make sure lessons were learned when things went wrong and to reduce the risk of recurrence.

Staff were kind and caring and people told us they were treated with respect.

People’s information was not always stored securely because office doors were left unlocked.

People were at risk of not consistently receiving care and support which met their needs and preferences because of shortfalls in their care records.

Complaints were investigated and responded to. However, a recent survey carried out by the provider showed an increasing number of people were not satisfied with the way their complaints had been dealt

The inspection took place on 1 and 24 August 2017 and was unannounced. The inspection on 1 August 2017 was a planned inspection to check the provider had taken action to address the breaches of regulation identified at the last inspection. The visit on 24 August 2017 was carried out in response to information of concern we received from a relative of a person who lived in the home.

The last inspection report was published in February 2017 following an inspection in November 2016. The overall rating for the service was inadequate. We found the service was in breach of five regulations, regulation 9 (person centred care), regulation 10 (dignity and respect), regulation 12 (safe care and treatment), regulation 17 (good governance) and regulation 18 (staffing). The service was placed 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.

Howgate House provides accommodation with nursing or personal care for up to 63 people over three floors. There is one bedroom which can be shared by two people and the remainder are single rooms. There are communal rooms on two floors and there is an accessible outside area. The building has access for people with disabilities and there is a passenger lift to all floors. At the time of our inspection there were 43 people living at the home.

The home did not have 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. A new manager had been appointed and was in the process of applying for registration at the time of our inspection.

Everyone we spoke with said the home provided a safe place for people to live. Staff were trained to recognise and report any concerns about people’s safety and welfare. The required checks on new staff were done before they started work and this helped to keep people safe.

Generally people were satisfied there were enough staff to meet their needs. However, we asked the provider to keep the staffing levels under review to make sure there were always enough staff available to meet people’s needs in a timely way.

People told us they had their medicines at the right time and overall we saw medicines were managed safely. Regular checks were carried out and when errors occurred action was taken to reduce the risk of recurrence.

Risks to people’s safety and welfare were managed although this was not always reflected in their care records.

The home was clean and well maintained.

Most people felt staff were adequately trained to meet people’s needs. However, one person felt staff would benefit from more training on supporting people living with dementia and dealing with behaviours which challenge. We saw staff received training on a variety of subjects. Staff told us they felt supported. Staff one to one supervisions had fallen behind schedule but there was a plan in place to address this.

People’s rights were promoted and protected and they were asked for their consent before care was provided. Where appropriate best interest decisions had been made on people’s behalf. People were treated with kindness and compassion and their privacy and dignity was respected.

People told us they enjoyed the food and were offered a choice. We found people’s dietary needs and preferences were catered for.

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People were supported to meet their health care needs and had access to a range of external health care

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, and to provide a rating for the service under the Care Act 2014. The inspection was unannounced. At the last inspection in January 2015 the home met all the national standards that we looked at.

Howgate House provides accommodation with nursing or personal care for up to 63 people over three floors. All the rooms are single rooms although there is one room which can be shared by two people. There is a lounge and dining area on two floors and disabled toilet and bathing facilities. The building has access for people with disabilities and there is a passenger lift to all floors.

We saw medicines were stored appropriately and saw people were not rushed when being supported with taking their medicines. However the management of medicines were not always recorded properly and medicines to be taken as and when required [PRN] did not have the documentation near the medicines for staff to refer to.

Care plans were reviewed regularly however any changes required were not altered in the original care records for people. We looked at care records for eight people and found the most up to date information had not been captured. This increased the risk of people receiving unsafe or inappropriate care and treatment.

Staff, people and relatives all told us they thought there was not always enough staff on duty to support people effectively. We made observations during our inspection that illustrated staff were task orientated. This meant people were sometimes left waiting when they needed support.

Risks to people had been assessed and in most cases staff had taken action to reduce these risks. However risk assessments were reviewed regularly, but the updated information was not always recorded on the original assessment. Inaccurate recording increased risks to people with reduced nutritional intake.

Equipment was not always fir for purpose. Call bells were not always left within reach for people. This left some people unable to call for help when they needed it.

Staff did not always know the current needs of the people they supported. Staff did not always share information effectively. Confidential information was sometimes left out, and staff were talking openly between each other in a communal area about people.

People were supported to stay healthy and to obtain medical treatment if they needed it.

The registered manager and staff acted in accordance with the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). People's capacity to make decisions had been assessed and meetings had been held to ensure that decisions taken about people who lacked capacity were made in their best interests. Applications for DoLS authorisations had been submitted where restrictions were imposed upon people to keep them safe.

People sometimes enjoyed the food provided and could have alternatives to the menu if they wished. However the menu did not always indicate the correct options for that day. People were not always given the support and encouragement they required to eat sufficient portions. We saw drinks were available if people asked for them but they were not left out for people to help themselves.

Staff were usually kind and sensitive to people's needs. People had positive relationships with the staff who supported them. Relatives had mixed reviews that staff provided compassionate care and were professional and caring.

Staff had access to the training, supervision and support they needed to do their jobs. New staff completed an induction and then a shadow period. Staff we spoke with told us the training was effective in supporting them to complete their roles. However, our observations showed training had not e

Howgate House provides accommodation with nursing or personal care for up to 63 people over three floors. All the rooms are single rooms although there is one room which can be shared by two people. There is a lounge and dining area on two floors and disabled toilet and bathing facilities. The building has access for people with disabilities and there is a passenger lift to all floors.

People had care plans were in place for each person. Plans included details about people’s personal preferences. We asked the registered manager about the care plans and they told us they had work to do to make them more persons centred. We saw recorded a message from the registered manager to staff about the addition of a likes and dislikes section.

We spoke with people that used the service and observed care and support being given to people. People told us they were happy living in the home and shared a positive relationship with staff. People also said they were treated with respect and dignity. We saw staff interacting with people, offering choice and promoting a positive experience. Staff followed the guidance in people’s car plans.

People had accessed health care professionals when required. We looked at people’s daily records and saw identified areas of concern followed by referrals being made to health professionals. People had weight charts in place with their weights checked regularly. Staff told us if someone’s weight dropped quickly, they would share that information with a more senior member of staff.

People had mainly positive comments about the food. Peoples told us portions were sufficient and alternatives were available if required. Menus were available for people to see. The registered manager told us the menus were created seasonally on a four week rolling set menu. We looked at the menu and saw overall balanced meals for people. Relatives told us their family member likes the food a certain consistency and the home were happy to accommodate for this.

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.

We looked at three staff files and saw supervisions and appraisals were taking place. The home had a training program which showed us that all staff had completed nearly all training within satisfactory time frames. Staff told us they were given time and support to complete the training. This showed us that all staff received appropriate support and training to complete their roles.

Medicines were administered in a safe way. We saw appropriately trained staff administered medicines to people. Staff supported one person with their medicines at a time. When medication was administered, staff returned to the administration record to sign it.

Staffing rotas showed us sufficient numbers of staff were on shift to keep people safe. We observed staff did not rush people and people told us they were not left for long periods. During the inspection we saw people were not left wanting for periods of time. During busy times of the day we saw people were responded to. This showed us appropriate numbers of staff worked to cover people’s needs.

The Care Quality Commission (CQC) monitors the operation of the DoLS (Deprivation of Liberty Safeguards) which applies to care homes. We saw restrictions on people’s liberty which could constitute a deprivation of their liberty. The registered manager told us they had made DoLS referrals in agreement with the DoLS team. We saw the home had made 20 referrals to the DoLS team.

We saw that accidents and incidents were recorded and analysed for trends. Accidents and incidents had been analysed on a monthly basis. The registered manager told us they looked for trends. Any findings were shared with senior staff. This showed us that accidents and incidents were monitored effectively.

A complaints policy and procedure was in place. Relatives and people that used the service that we spoke with told us they knew how to make a complaint and they felt senior managers would listen and take it seriously. Staff told us how they would refer people’s complaints and where they would record it. Staff said verbal complaints would be documented.

The registered manager ensured a robust programme of quality assurance was in place. We saw the home used an external company to assess their quality. This produced a report that reflected some of the areas the Care Quality Commission (CQC) inspect against. The registered manger told us this was to be updated to reflect the new regulations.

During the visit we had the opportunity to speak with four people who used the service and two relatives. People told us they were very pleased with the care and support provided at Howgate House. Relatives told us they were involved in discussions and decisions about their relatives care needs and were kept informed about any changes. One person said "I'm happy with everything" and another said their relative was, "Well looked after". Everyone said the staff were very approachable and supportive.

We found the provider had systems in place which ensured consent was gained before they proceeded with personal care. People told us they could make choices and decisions about how they wanted to spend time at Howgate House and staff encouraged them to be involved in making decisions about their care and treatment.

We spoke with staff that told us there is a seasonal menu which was changed on a monthly basis. People who lived in the home and their relatives said they get a good choice of food. One person told us they ordered a specialty meal once a month.

We found people were protected from the risk of infection as care was delivered in a clean and hygienic environment.

We found that records were held securely and were produced when requested.

During the visit we had the opportunity to speak with four people who used the service and five relatives. Everyone told us they were very happy with the care and support provided at Howgate House.

Relatives told us they were involved in discussions/decisions about their relatives care needs and were kept informed about any changes. One said "we recommended the home to others and they moved in and like it." Everyone said the staff were wonderful and very approachable and supportive.

People who lived in the home and their relatives said the food was "very good" and the home was clean and comfortable.