About the service: Howson Care Centre 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. It provides accommodation for people living with a learning disability and/or with mental health conditions or dementia. The home can accommodate up to 83 people. The home is divided into six units. The units are, The Court, The Main House, The Wing, The Laurels, The Flat and The Bungalow. At the time of our inspection there were 79 people living in the home.

People’s experience of using this service:

There was a system in place to support managers to carry out quality checks. The acting manager had started to carry these out on a regular basis, however these checks had not been in place long enough to understand the impact these would have on the service.

Medicines were managed safely. Arrangements were in place to monitor and manage medicines safely.

Staff told us that there was usually sufficient staff but that some units had more difficulty than others in ensuring there was sufficient staff.

People enjoyed the meals and their dietary needs had been catered for. This information was detailed in people’s care plans.

Staff followed guidance provided to manage people's nutrition and pressure care.

The care plans had been reviewed and contained information about people and their care needs.

Staff had not consistently received training to support their role, however plans were now in place to address this.

Staff had started to receive regular supervision and plans were in place to ensure people received this on a regular basis.

People had good health care support from professionals. When people were unwell, staff had raised the concern and taken action with health professionals to address their health care needs. The provider and staff worked in partnership with health and care professionals.

Staff were aware of people's life history and preferences and they used this information to develop positive relationships and deliver person centred care. People felt well cared for by staff who treated them with respect and dignity.

There was a range of activities on offer. The acting manager was looking at how they could develop this area further.

The environment in the Court was not adapted to support people living with dementia. However, a refurbishment plan was in place to address this.

The provider had displayed the latest rating at the home and on their website. When required notifications had been completed to inform us of events and incidents.

More information is in the detailed findings below.

Rating at last inspection: Requires Improvement (Report Published 30 July 2018). At our previous inspection in May 2018 the service was rated overall requires improvement. We found continued breaches of Regulation 17 and 12 HSCA 2008 (Regulated Activities) Regulations 2010 and a breach of Regulation 18 Registration Regulations 2009, the provider had failed to inform us of accidents and incidents.

At this inspection we found the regulations were being met. There were improvements in the management of medicines and quality monitoring systems. However, these improvements had not fully taken effect because they had only recently been introduced. We have taken this into account in determining the rating.

Why we inspected: This was a scheduled inspection based on the previous rating.

Follow up: Arrangements are already in place for the provider to provide regular monitoring reports. We will continue to receive these and continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

Howson Care Centre is a ‘care home with nursing’. 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. It provides accommodation for older people, people living with a learning disability and those with mental health conditions or dementia. People living at the home were a mixture of ages. Many of the people living at the home had complex needs. Some people required more assistance either because of physical or psychological illnesses or because they were suffering from memory loss. The home can accommodate up to 83 people. At the time of our inspection there were 79 people living in the home. Care is provided in six units which are based on a single site. The units are The Main house, The Court, The Wing, The Flat, The Laurels and The Bungalow.

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. In this report when we speak about both the company and the registered manager we refer to them as being, ‘the registered persons’.

At the last inspection the service was rated, ‘Requires Improvement’. We found breaches in Regulation 12 and Regulation 17. Care plans were not put together with people who used the service. They were not reviewed on a regular basis and did not reflect the needs and wishes of people. Quality checks on the service were not robust enough and lessons learnt not passed on to staff to improve the service. At the last inspection in October 2016, we asked the provider to take action to make improvements to care records and quality monitoring. At this inspection we found although there had been some improvements in care records their remained issues regarding the review of these and in the management of quality checks.

This is the third time the service has been rated ‘Requires improvement’. We found there remained a breach of Regulation 17.

Quality checks were being completed but these had not identified some of the issues we found at inspection. Issues identified at previous inspections had not been addressed fully. The provider had failed to inform us about accidents and incidents.

Medicines were not managed consistently safely. Where people received their medicines without their knowledge (covertly) the provider had not followed best practice guidelines. Arrangements were not in place to ensure medicines were administered at the correct interval.

Where people were unable to make decisions arrangements had been made to ensure decisions were made in people's best interests. However not all best interests decisions were issue specific as required by national guidance.

The provider had ensured that there was enough staff on duty. In addition, people told us that they received person-centred care.

There were systems, processes and practices to safeguard people from situations in which they may experience abuse including financial mistreatment. Risks to people’s safety had been assessed, monitored and managed so they were supported to stay safe while their freedom was respected. Background checks had been consistently completed before new staff had been appointed.

There were arrangements to prevent and control infections however these had failed to address issues we identified at the inspection.

Staff had been supported to deliver care in line with current best practice guidance. People were helped to eat and drink enough to maintain a balanced diet. People had access to healthcare services so that they received on-going healthcare support.

People were supported to have choice and control of their lives and to mai

We inspected Howson Care Centre on 25 October 2016. This was an unannounced inspection. The service provides care and support for up to 83 people. When we undertook our inspection there were 79 people living at the home. This is a large premises which is split into different units to take into consideration the different types of people the provider is registered to provide services for, such as people with mental health problems, physical disabilities and those living with dementia.

People living at the home were of mixed ages. Some people required more assistance either because of physical illnesses, mental health needs or because they were experiencing difficulties coping with everyday tasks, with some having memory loss.

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’s health care needs were assessed, but care was not planned and delivered in a consistent way through the use of their care plans. People were not involved in the planning of their care. The information and guidance provided to staff in the care plans was unclear. Risks associated with people’s care needs were assessed, but plans were not put in place to minimise risk in order to keep people safe.

The care plans and risk assessments did not fully reflect the needs of people and what action staff should take to prevent a person from being at risk of harm. The clinical governance measures were not robust enough and did not reflect whether lessons had been learnt from audits to measure the quality of the service. You can see what action we told the provider to take at the back of the full version of the report.

People had been consulted about the development of the home. However, the auditing system was poor and there was no analysis of quality checks, or lessons learnt passed on to staff.

You can see what actions we told the provider to take at the back of the full version on the report regarding the review of care plans and ensuring quality checks are more robust.

CQC is required by law to monitor the operation of the Mental Capacity Act 2005 Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are in place to protect people where they do not have capacity to make decisions and where it is considered necessary to restrict their freedom in some way, usually to protect themselves. At the time of our inspection there was one person subject to such an authorisation.

We found that there were sufficient staff to meet the needs of people using the service. The provider had taken into consideration the complex needs of each person to ensure their needs could be met through a 24 hour period. The home was divided into different units and a core staff worked in each unit, with some staff working across units depending on people’s needs.

People were treated with kindness and respect by the majority of staff. Staff in the home took time to speak with the people they were supporting. However, some staff had a poor attitude to people and did not treat them with respect. The staff on duty knew the people they were supporting and the choices they had made about their care and their lives. People were supported to maintain their independence and control over their lives.

People had a choice of meals, snacks and drinks. Meals could be taken in dining rooms, sitting rooms or people’s own bedrooms. Staff encouraged people to eat their meals and gave assistance to those that required it. However, there were no menus on display so people could not remind themselves of the choices they had made.

The provider used safe systems when new staff were recruited. All new staff completed training before workin

We inspected Howson Care Centre on 11 August 2015. This was an unannounced inspection. Our last inspection took place on 17 September 2014 and the service was compliant. The service provides care and support for up to 83 people. When we undertook our inspection there were 78 people living at the home.

People living at the home were a mixture of ages. Some people required more assistance either because of physical or psychological illnesses or because they were suffering from memory loss. People had a choice of four units to live in and suggestions were made by staff as to the right type of unit which would meet people’s needs.

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.

CQC is required by law to monitor the operation of the Mental Capacity Act 2005 Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are in place to protect people where they do not have capacity to make decisions and where it is considered necessary to restrict their freedom in some way, usually to protect themselves or others. There were three people subject to such a DoLS authorisation.

We found that there were insufficient staff to meet the needs of people using the service. The provider had not taken into consideration the complex needs of each person to ensure their needs could be met through a 24 hour period. The deployment of staff when someone required one to one care was poor.

We found that people’s health care needs were assessed, and care planned and delivered in a consistent way through the use of a care plan. People were involved in the planning of their care and had agreed to the care provided. The information and guidance provided to staff in the care plans was clear. Risks associated with people’s care needs were assessed and plans put in place to minimise risk in order to keep people safe.

People were treated with kindness, compassion and respect. The staff in the home took time to speak with the people they were supporting. We saw many positive interactions and people enjoyed talking to the staff in the home. The staff on duty knew the people they were supporting and the choices they had made about their care and their lives. People were supported to maintain their independence and control over their lives.

People had a choice of meals, snacks and drinks. And meals could be taken in dining rooms, sitting rooms or people’s own bedrooms. Staff encouraged people to eat their meals and gave assistance to those that required it.

The provider used safe systems when new staff were recruited. All new staff completed training before working in the home. The staff were aware of their responsibilities to protect people from harm or abuse. They knew the action to take if they were concerned about the welfare of an individual.

People had been consulted about the development of the home. Quality checks had been completed to ensure services met people’s requirements. However, actions from those checks and from surveys and staff meetings had not been followed through. Therefore we did not know whether staff had learnt lessons from quality checks and were ensuring a quality service was given at all times.

This was a follow up visit from our inspection on 03 and 06 June 2014. We had set a compliance action because some areas of the grounds were unsafe to use and the provider was not adhering to their own policy of completing maintenance checks. Also at the time of our last inspection the last set of surveys issued to people who used the service and staff had not been analysed.

During this inspection our inspection team was made up of one inspector. We considered our evidence to help us answer two of our five questions we always ask; Is the service safe? and Is the service effective?

Below is a summary of what we found. The summary is based on our observations during the inspection on 17 September 2014, speaking with the staff and from looking at records.

Is the service safe?

Since our last visit all broken furniture had been removed and replaced with new items. Walkways had been cleaned and decking repainted. New fencing ensured people could walk safely to the edge of pathways. Hedging had been cut back enabling people to have views over fields and the village sports grounds.

There were no trip hazards on walkways and the grounds had been made safe to use.

Receptacles had been provided to ensure people could extinguish their cigarettes.

Is the service effective?

Records showed and staff told us the maintenance staff walked around the grounds weekly to see which areas needed any repairs. Staff alerted the maintenance staff and manager, verbally and on written records, when items were required to be urgently repaired.

A new system was in place to ensure results from surveys issued to people who used the service and staff were analysed and actions followed through. The next survey was later in the year.

People told us what it was like to live at Howson Care Centre. They described how they were treated by staff and their involvement in making choices about their care. They told us that the staff team provided the support and care they needed.

During our visit we spoke with nine people who lived at the home, five members of staff and the deputy manager.

We observed that staff provided sensitive support using special equipment when people needed help with moving safely, during meal times and when people were undertaking individual or group activities.

For example, when observing a staff member giving support to one person who was upset and unsettled the staff member gently said, “Would you like to come with me and we can do something different.” We saw that the person responded well to being give this choice, became calm and communicated that they were happy to go with the staff member.

We also observed how people enjoyed the food that the home provided and the social activities that the home had organised.

There were opportunities for people to go out into the community with support from staff and their relatives when they had chosen to. One person told us that, “We go swimming every week and walking every week. I want to keep healthy.”

We saw people getting ready to go out in the homes mini bus and one person told us, “We are going to Mablethorpe because it is sunny and I can’t wait.”

Another person told us, “It’s perfect for me. There is a lot do here and the things I like to do, we do.”

When we visited Howson Care Centre people told us they were happy with the care they received.

People we spoke to told us that their care needs were being met in the way they wished and that staff were always there when they needed them.

People also told us they could make their own choices about the things they liked to do and were supported by the staff team to go out into the community or on holidays if they wished.

One person told us about a holiday that some of the people had been on recently saying, "It was great, we did lots of walking and I felt safe going".

Other people told us about their individual and group activities. One person said, "I am off swimming today. I like to go because it keeps me fit and I like the company".

Another person said, "I have ordered some plants and I am going to plant them in the garden. I like gardening and the staff help me get the things I want."

People did not tell us their views about the service in detail. However, we spent time observing how peoples needs were being met.

We watched some people being given their medicines at lunchtime and saw that the correct medicines were given. Each person's medicine chart was signed immediately after administration. One person told us “I have everything I need”.

We also observed that some people were given their morning medicines at lunchtime as they had chosen to get up late. This did not put people at risk of harm but, with the exception of one person's antibiotic, the actual time of administration was not written on the chart.

Our inspection team on this occasion was made up of two inspectors. We considered our evidence to help us answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with nine people who used the service, the staff supporting them and from looking at records. We spoke with nine staff members plus the manager and the deputy manager. We looked at eight care plans. The provider also sent us information immediately after the visit.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People were treated with respect and dignity by the staff. People told us they felt safe.

Safeguarding procedures were robust and staff understood how to safeguard the people they supported.

Systems were in place to make sure that managers and staff learnt from events such as accidents and incidents. This reduced the risks to people and helped the service to continually improve.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications had needed to be submitted, proper policies and procedures were in place. Staff knew what documentation they were required to complete.

The service was safe, clean and hygienic. Equipment, for people's personal use, was well maintained and serviced regularly, therefore people were not put at unnecessary risk.

Is the service effective?

People's health and care needs were assessed with them, and they were involved in writing their plans of care. Specialist dietary, mobility and equipment needs had been identified in care plans where required. People said that they had been involved in writing them and they reflected their current needs.

People's needs were taken into account with signage and the layout of the service enabling people to move around freely and safely. People were continually assessed and could move from unit to unit if their needs changed.

People told us they could express their views at group meetings and meetings on a one to one basis.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people.

People commented, "It's is one hundred per cent safe and secure. I'm well looked after" and "Staff are ace, it's the best place to live."

People who used the service, their relatives, friends and other professionals involved with the service attended meetings throughout the year. Where shortfalls or concerns were raised these were addressed. People told us they felt their opinions were valued.

People's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people's wishes.

Is the service responsive?

People told us they could speak with staff each day and share their concerns. They told us staff acted quickly.

Is the service well-led?

The service worked well with other agencies and services to make sure people received their care in a joined up way.

The service had a quality assurance system. Records seen by us showed that identified shortfalls were addressed. As a result the quality of the service was continuously improving.

However, when staff and people who used the service completed surveys about the quality of care the provider did not analysis the results so could not inform staff if improvements needed to be made.

The provider needed to ensure they were keeping to it's own policy about checking the maintenance of the outside of the buildings to ensure all areas were safe to use and there were no broken pieces of furniture around.

Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home and quality assurance processes that were in place. This helped to ensure that people received a good quality service at all times.