This inspection took place on 17 and 20 September 2018 and was unannounced. The inspectors returned to conclude the inspection announced on 21 September 2018.

The Haven Rest Home is registered to provide accommodation and personal care for up to 17 older people including people who may be living with dementia. The Haven Rest Home 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.

At the time of our inspection there were 15 people living at the home, who were accommodated in one adapted residential building.

The provider had appointed an acting manager who was present at the time of the inspection as the registered manager had been absent on leave since November 2017. 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.

At the last inspection of the service on 17 and 18 December 2015 the service was rated as 'Good' overall with Requires Improvement in the key question of Effective. On this inspection we found the provider had not maintained their rating of Good overall and we have changed the rating to Requires Improvement overall.

The provider did not have effective systems to ensure all statutory notifications were sent to the Care Quality Commission. The provider had failed to notify us of incidents and Deprivation of Liberty Safeguard authorisations as they are required to do by law.

The management of a medicine which required special storage because of the potential to misuse was not accounted for in the providers recording procedures. This had not been identified by the provider because the checks that had been undertaken were ineffective.

The provider had not ensured the home environment was visibly clean in all areas with suitable hand washing facilities made available, especially communal toilets. Staff were seen to wear protective clothing when undertaking their caring roles which required them to do so to reduce the risk of the spread of infections, except for when entering the kitchen area.

The needs of people who lived with dementia were not reflected in the home environment to ensure it had been adapted and designed to meet these. Amongst other things there was lack of directional signage to assist people and there were various cleaning products in an unlocked room which did not mitigate the risks to people’s health and safety.

Staff did not show through their caring practices that people’s privacy, dignity and right to confidentiality was consistently promoted.

There was not a robust quality assurance process in place. Audits to assess the quality of service provision were ineffective in identifying some of the improvements needed.

Systems for the safe recruitment of staff were not robust, and recruitment files showed there had been gaps in the recruitment process that had potentially put people at risk. Staff received an induction which was based on the providers expectations of their staff team and ongoing management support to assist staff to continually improve in their roles. Some staff practices did not consistently reflect the knowledge they had obtained to ensure they undertook their roles effectively.

Staff received training in, and understood, their responsibility to protect people from abuse and neglect. The risks associated with people’s care and support needs had been assessed and staff were knowledgeable about the equipment people required to meet their individual needs. The provider kept staffing numbers under review and had increased these to meet people’s needs safely.

People's individual needs and requirement

The inspection was unannounced and took place on 5 November 2014.

The Haven Rest Home is registered to provide accommodation and personal care for adults with a dementia related illness for a maximum of 17 people. There were 16 people living at home on the day of the inspection. 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.

People told us that they felt safe and well cared for with enough staff to meet their needs. Staff were able to tell us about how they kept people safe. During our inspection we observed staff were not always available to meet people’s care and social needs because incidents had not been reviewed to prevent them from happening again. This was because at times we saw that people were left in the communal lounge where staff had not been available. We saw that at time this put people at risk of falls or injury.

We have made a recommendation about assessing people’s individual health and environmental risks.

The provider was not reporting safeguarding incidents to the local authority and CQC in line with their legal responsibilities. This would ensure that people were protected and the appropriate investigations were completed relating to each person involved. The provider was not meeting this regulation.

People received their medicines as prescribed and at the correct time. However, we found systems and processes needed to be improved to ensure people were given medicines that were stored and able to be identified correctly. This would ensure people who required medicines as needed received them when required. The provider was not meeting this regulation.

People told us they liked the staff and felt they knew how to look after them. Staff were provided with training which they felt reflected the needs of people who lived at the home. However, staff did not demonstrate a full understanding of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). At the time of our inspection three people had an application submitted to deprive them of their liberty. The registered manager had been supported to make these applications on the advice of social workers.

Assessments of people’s capacity to consent and records of decisions had not been completed in their best interests. The provider could not show how people gave their consent to care and treatment or how they made decisions in the person’s best interests. Therefore, people had decisions made on their behalf that may not have been in their best interest. The provider was not meeting this regulation.

People and relatives told us there were enough staff to support people at the home. Staff at the home felt there were enough staff to meet the needs of people living at the home. They also told us that extra staff were available at busy times if required.

People were supported to eat and drink enough to keep them healthy. We found that people’s health care needs were assessed, and care planned and delivered to meet those needs. People had access to other healthcare professionals that provided treatment, advice and guidance to support their health needs although these had not always been followed.

People told us and we saw that their privacy and dignity were respected and staff were kind to them. However, on occasions we saw staff had not always been understanding and supportive of people’s choice and decisions.

We have made a recommendation about staff training on the subject of dementia.

People had not always been involved in the planning of their care due to their capacity to make decisions. However, relatives told us they were involved in their family members care and were asked for their opinions and input.

People told us they would prefer more things to do during the day. People said that they did go out occasionally. People we spoke with told us they were not aware of the provider’s complaints policy, however were confident to approach the manager if they were not happy with their care.

We have made a recommendation that people living with dementia related illness receive care and support to maintain their hobbies and interests.

The provider and registered manager made regular checks to monitor the quality of the care that people received and look at where improvements may be needed. However, we found that improvements were needed to ensure that the audits helped the provider to identify where regulations were not being met.

We have a made a recommendation about developing and supporting the registered manager and staff knowledge to provide care that reflects current MCA legislation and dementia care best practice.

We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.

We were unable to speak with some people as they had limited communication. We spoke with three people and observed how staff interacted with people. We spoke with the provider, the care manager a care worker and a visiting professional.

We overheard staff ask for consent before they attemped to provide care for people. We saw that people had opportunities to make choices about their personal references and that staff respected the decisions they made. One person told us: "I like to have a bath. Staff ask me if I'm ready to have it".

People’s needs had been assessed and care and treatment was planned and delivered in line with their individual wishes. One person said: "I am looked after pretty well". We found that there were systems in place for the safe administration of medicines that promoted people's health and well-being.

People were cared for, or supported by suitably qualified, skilled and experienced care workers. The provider had robust recruitment processes in place and had made appropriate checks before they offered employment. This protected people from risks of harm.

People were encouraged to exercise their rights in making a complaint if they were not happy with the services provided to them. The people we spoke with told us they were satisfied with the care they received and had never made a complaint.

To carry out our inspection we visited the home on 3 July 2012. We spoke with one person who was using the service. This is because most people were unable to communicate effectively due to their health conditions. We used a number of different methods to help us understand the experiences of people using the service. They included looking at care files, observing staff practices, reviewing staffing levels, the quality of the service, talking with a relative and the provider.

We saw that people in the home were comfortable and relaxed within their environment. We saw that care workers interacted well with people; they were friendly, helpful and gently encouraged people to remain as independent as possible.

We saw that people were receiving their personal care in a way that included their personal preferences.

One person using the service said:

“I ain’t half lucky to be here”.

A relative told us:

“Excellent, they couldn’t do any more for X if they tried”.

We watched the activities organiser who encouraged people to participate in a range of activities that promoted mental stimulus, physical exercises and a sing-a-long. Some people chose not to take part and staff respected the decisions that people made. Care workers provided assistance to others who did take part.

There were systems in place to protect people from harm and staff knew how to respond if abuse was suspected. We found that the home was adequately staffed to care for the number of people who were living there.

The quality of the services provided had been audited and were found to be appropriate. The home had a complaints procedure on display to provide people with guidance if they or their relatives were not satisfied about any part of the services. The comments we received from people and review of the complaints file confirmed that people were happy to live at the home.

We carried out an unannounced comprehensive inspection of this service on 5 November 2014. Breaches of legal requirements were found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to management of medicines, regulation 13 of the Health and Social Care Act 2008 (Regulated activities) Regulations 2010, safeguarding people who use services from abuse, regulation 11 of the Health and Social Care Act 2008 (Regulated activities) Regulations 2010 and consent to care and treatment, regulation 18 of the Health and Social Care Act 2008 (Regulated activities) Regulations 2010.

We undertook this inspection on 30 November and 1 December 2015 to check that they had followed their plan and to confirm that they now met legal requirements.

The home is registered to provide accommodation and personal care for a maximum of 17 people. There were 16 people living at the home on the day of the inspection. 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.

On the day of our inspection the registered manager was on a period of extended leave. In response to this the provider had made cover arrangements. An acting manager had been appointed and the provider had been visiting the home frequently to provide support.

During our inspection on the 30 November and 1 December 2015, we found that the provider had followed their plan which they had told us would be completed by the 20 May 2015 and legal requirements had been met.

People were 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 safely supported.

People were cared for by staff who had a good understanding of of protecting people from the risk of abuse and harm. Staff knew their responsibility to report any concerns and were confident that action would be taken.

People needs were met promptly. Both relatives and staff said that there were sufficient staff numbers to meet people’s needs and we saw staff responding to people in a timely way.

Whilst improvements had been made in the assessment of people’s capacity, in talking to the acting manager and provider we found they had not consistently applied the principles of the Mental Capacity Act 2005 (MCA). For example, exploring the least restrictive options and fully considering the impact on other people. Care staff spoken to had limited knowledge of the MCA and how this impacted on the care provided to people and needed support to access training.

People enjoyed the food they received and relatives were positive about the choice of food given. People were supported to access health and social care professionals with regular appointments when needed and were supported by staff to attend these appointments.

Relatives were positive in their feedback about the service and confirmed they were involved in making decisions about care and treatment. Relatives told us people’s privacy and dignity was maintained by staff and we made observations that supported this.

People received care that met their individual needs. Relatives and staff said managers listened to them and they felt confident they could raise any issues should the need arise.

Relevant notifications had not consistently been submitted to CQC where safeguarding reports had been referred to the local authority. CQC requires this information to look at the risks to people who use care services.

The provider and managers were accessible and approachable and the provider ensured regular checks were completed to monitor the quality of care.