We inspected the Hurst Residential Home on the 21 and 27 March 2018. This was an unannounced inspection.

The Hurst Residential Home is registered to provide accommodation and support for people who experience mental health difficulties including depression, anxiety and personality disorders. The home can provide care and support for up to 29 people. There were 13 people living at the home during our inspection. Accommodation is provided over two floors with communal lounge and dining areas. The Hurst Residential 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 a comprehensive inspection in January and February 2015 the overall rating was Inadequate and we took appropriate enforcement action at that time. Following the inspection, we received an action plan which set out what actions were to be taken to achieve compliance. We undertook a focussed inspection in December 2015 to see if improvements had been made. Whilst we could see that some action had been taken to improve people’s safety, the poor management of risk to individual people remained. Improvement was still needed to ensure people received support in a person centred way and that care and treatment of people had not been provided with the consent of the relevant person. There were still concerns in respect of the quality assurance systems to drive improvement. We received an action plan from the provider that told us how they were to meet the breaches of regulation by December 2016. We undertook a comprehensive inspection in January and February 2017. We found that whilst there were areas still to improve and embed in to everyday practice, there had been significant progress made and the breaches of regulation previously found had been met. We however found a new breach of regulation in that care plans did not reflect changes to people’s needs and therefore people had not received person centred care. The overall rating in February 2017 was requires improvement.

Following the last inspection in February 2017, we asked the provider to complete an action plan to show what they would do and by when, to improve the key questions safe, effective, caring, responsive and well led to at least good. This inspection found improvements had been steadily made and the breach of regulation met. However it was acknowledged that there were still improvements to make, care delivery and practices to embed into everyday practice. The action plan supplied during the inspection identified timescales for areas of improvement to be completed. This was the second consecutive time the overall rating was ‘Requires Improvement’.

A registered manager was 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 and associated Regulations about how the service is run.

Care plans lacked sufficient information on some people’s individual specific health needs. There were people who lived with diabetes, catheters and pressure wounds whose care plan lacked the detail required to provide safe and effective care. These were immediately updated by the registered manager and the risk to people reduced. However there remained a need for the care plans and risk assessments to be continually reviewed and updated to reflect people’s individual needs.

The provider had progressed quality assurance systems to review the support and care provided. However improvements were needed to ensure that an independent overview was also undertaken to capture where improvements were needed alongside the internal audits.

We have made a recommendation about systems being implemented to compl

We inspected the Hurst Residential Home on the 31 January and the 3 February 2017. This was an unannounced inspection.

The Hurst Residential Home is registered to provide accommodation and support for people who experience mental health difficulties including depression, anxiety and personality disorders. The home can provide care and support for up to 29 people. There were 13 people living at the home during our inspection. Accommodation is provided over two floors with communal lounge and dining areas.

At a comprehensive inspection in January and February 2015 the overall rating was Inadequate and we took appropriate enforcement action at that time. Following the inspection, we received an action plan which set out what actions were to be taken to achieve compliance. We undertook a focussed inspection in December 2015 to see if improvements had been made. Whilst we could see that some action had been taken to improve people’s safety, the poor management of risk to individual people remained. Improvement was still needed to ensure people received support in a person centred way and that care and treatment of people had not been provided with the consent of the relevant person. There were still concerns in respect of the quality assurance systems in place to drive improvement. We received an action plan from the provider that told us how they were to meet the breaches of regulation by December 2016.

This unannounced comprehensive inspection on the 31 January and 3 February 2017 found that whilst there were areas still to improve and embed in to everyday practice, there had been significant progress made and that they had now met the breaches of regulation previously found.

We did however identify a breach of Regulation.

A registered manager was 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 and associated Regulations about how the service is run.

Care plans lacked sufficient information on people’s individual social well-being and specific health needs. Where people’s health needs had changed, such as reduced mobility, care plans did not reflect the changes and therefore new staff may not be aware of important changes to ensure peoples safety.

Information was not always readily available on people’s life history and the reasons why they had to come to live at The Hurst Residential Home. There were no specific goals identified for those who were only there for short term care. The lack of meaningful activities for people at this time impacted negatively on people’s well-being.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The registered manager and staff had an understanding of their responsibilities and processes of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. However there were areas to improve in regards with mental capacity assessments and best interest meetings.

This inspection showed that the provider had progressed quality assurance systems to review the support and care provided. A number of audits had been developed including those for accidents and incidents, care plans, medicines and health and safety. Maintenance records for equipment and the environment were up to date, such as fire safety equipment and stair lifts. Policies and procedures had been reviewed and updated and were available for staff to refer to as required. Staff said they were encouraged to suggest improvements to the service and relatives told us they could visit at any time and, they were always made to feel welcome and involved in care decisions.

Staff and relatives felt there were enough staff working in the home and relatives said staff were available to support people wh

We carried out an unannounced comprehensive inspection of this service on 21 and 23 February 2015. We identified improvements were needed with requirements relating to safe care and treatment, staffing, fit and proper persons employed, safeguarding service users from abuse and improper treatment, need for consent, meeting nutritional and hydration needs, person-centred care and good governance.

We undertook an unannounced focused inspection on the 09 December 2015 to check that the registered manager had made improvements and to confirm that legal requirements had been met. This report only covers our findings in relation to those requirements.

There were 14 people living at the service. The service was registered to provide accommodation and personal care for a maximum of 29 people. Older and younger people with physical, mental health and sensory loss needs, people who were previously homeless and people living with dementia received care and treatment at the service. The local authority put in place a suspension after the inspection in February 2015 due to the concerns we identified. No new admissions to the service had been made since this inspection.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the care and has the legal responsibility for meeting the requirements of the law. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

At our focused inspection on 09 December 2015, we found that improvements had been made since the last inspection, however not all legal requirements had been met. Some concerns with regard to staffing, the need for consent, person centred care and good governance identified at the inspection in February 2015 had not been sufficiently addressed.

The registered manager had not taken account of people’s social, emotional and therapeutic needs when determining staffing levels. This did not support improved quality of life outcomes or promote improvements in people’s mental health and well-being. There was insufficient contingency planning in place when staff members were on leave of absence at the same time, for extended periods. Staff had to work longer hours and shifts to address this shortfall in available staff. The registered manager had not been able to recruit sufficient high calibre staff to embed service improvements. The lack of staff structure in place to support the registered manager in their management of their responsibilities had not adequately improved since the last inspection.

Staff had received training on the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). This legislation sets out processes to follow when people do not have capacity to make their own decisions and what guidelines must be followed to ensure people’s freedoms are not unlawfully restricted. However the registered manager acknowledged that staff were not confident in applying the principles of the MCA in practice to ensure they provided care and support that people consented to in the least restrictive way. Recorded assessments of people’s mental capacity did not consistently reflect people’s needs and several applications for DoLS were still in progress. The process for the practical implementation of the MCA and DoLS was not yet fully effective.

The registered manager had not made sufficient improvements to provide activities suitable for people with mental health needs and for people living with dementia. Not everyone was happy with activities available to them.

People’s care plans were due to include an ‘About Me’ form to record more information about people’s pre-admission history and personal histories. This would enable staff to better understand the needs and preferences of people and provide more person-centred care. Four out of fourteen care plans had been updated with people’s personal history forms at the time of our inspection. Care plans had not recorded outcome goals, skills development goals, recovery goals and actions needed to meet those goals. Activity records for the current and previous months were not always completed. It was not recorded how frequently people engaged in activities at the home or were supported to access the community. These concerns were identified at the last inspection and had not been adequately addressed.

There was insufficient detail and guidelines for staff to administer people’s PRN medicines safely. The lack of information on the PRN forms and people’s care plans could increase the risk of people not receiving PRN medicines in line with people’s individual guidelines. The registered manager had developed a resource folder intended to develop staff knowledge of people’s needs, possible side effects and any signs of concern they needed to be aware of. This had not been made available to staff at the time of this inspection. Therefore staff did not have the information they required to always give medicines in line with the safe procedures and according to people’s needs.

Improvements had been made to the management of medicines. This ensured that people received their medicines safely and in line with their prescriptions. However poor practice was identified that had not been recognised or recorded as part of the provider’s medicines audit. We have made a number of recommendations to promote good practice in medicines management.

We have made a recommendation about protocols to record people’s preference for administration of medicines.

We have made a recommendation about PRN information on MAR and people’s care plans to reduce the potential risk of medicines errors.

We have made a recommendation about the provider making sure external medicines audits take place.

Some improvements had been made to the quality assurance systems. The registered manager had put in place a service improvement plan, however further improvements were needed as there were still some shortfalls remaining from the previous inspection. The registered manager had not systematically reviewed and implemented the necessary improvements as identified at the last inspection.

The registered manager had put in place protocols and guidelines for staff to follow to provide safe and effective care in the event people had a fall. The registered manager had made improvements to care plans where people had physical health needs to include epilepsy and diabetes. People’s care plans contained guidance and information for staff to provide safe and effective care.

Staff had completed basic training in essential standards of care. However the registered manager acknowledged in some areas staff did not have the competence or knowledge to apply training in practice.

We have made a recommendation about monitoring, recording and developing staff competence in practice.

We received mixed feedback about the quality of the meals and snacks provided. Some people were satisfied with meals provided and for other people the quality and availability of food did not meet their preferences or satisfaction.

We have made a recommendation about consultation with people about their food preferences to ensure people’s needs are consistently met.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

A single inspector carried out the inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

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

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

This is the summary of what we found:

Is the service safe?

People were treated with respect and dignity by the staff. People told us they felt safe. Safeguarding procedures were in place and staff understood how to safeguard the people they supported. One person who uses the service told us “I feel safe living here, everyone is so kind”.

Systems were in place to make sure that both managers and staff learn from events such as accidents and incidents, complaints and concerns.

Policies and procedures were in place to make sure that unsafe practices were identified and the people were protected.

Is the service effective?

People we spoke with told us they were happy with the care they received and felt their needs had been met. From what we observed and also speaking with the staff it was clear that they understood people’s care and support needs and they knew them well. One person told us “If I need any help with anything the staff are always there for me”.

Staff had received training and development to meet the needs of the people living at the home.

Is the service caring?

Staff were attentive and kind to the people who needed support. Staff told us they encouraged people to maintain their independence. We saw staff were patient and attentive to the needs of the people when supporting them.

People’s preferences, interests and diverse needs had been recorded in the care plans we viewed.

People using the service were offered a resident quality assurance survey to complete. Where shortfalls or concerns were raised they had been addressed and discussed with the person.

Is the service responsive?

People’s needs had been assessed before they moved into the home. Information had been recorded on detailed care and support plans. People told us they regularly discuss their needs with their support worker.

People knew how to make a complaint if they were unhappy. The complaint’s policy was displayed on a notice board to remind people.

People living at the home completed a range of activities. One person we spoke with told us “we do lots of different things, yesterday we went out for lunch which was lovely”.

Is the service well-led?

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

A quality assurance system was in place and records we viewed identified shortfalls and these were being addressed by the manager. As a result the quality of the service was continuingly improving.

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

We used a number of different methods to help us understand the experiences of people who used the service because some people had complex needs which meant they were not able to tell us their experiences.

There were 13 people living in the home on the day of our inspection visit. One person told us they were, “Happy living here.” Another said that they were, “Well cared for,” and that, “Staff are nice.” One person expressed sadness about staff they liked who had left. However, they told us they liked living in the home. We observed good interaction between staff and people who lived in the home. Staff demonstrated good knowledge of people’s needs. We saw some people going out shopping on their own.

We spoke with three external health care professionals. They all said that staff complied with any advice and requests on care and treatment for people who used the service. They told us they received appropriate and timely referrals.

We found improvements in staff training with staff training needs assessed and a programme in place. We found that communication between the manager and staff had improved. The manager had undertaken relevant training for the role with a plan in place for continued update and development. There was evidence of good record keeping and regular review of people’s care plans and risk assessments.

We spoke with four people who used the service. One person told us that they had settled well at the home and considered they were being well cared for. Another person said, “I am very happy here.”

We observed that staff treated people with kindness and professionalism.

We spoke to one visiting healthcare professional during our visit. They told us, “The staff take on the clinical information and they act on it. Information is shared with staff (about people’s needs).”

We saw that processes relating to the response to and recording of falls had been improved. Staff that we spoke with were aware of their responsibilities in the updated procedure.

We spoke with four staff, the team leader and the manager. Staff told us that the number of staff working in the afternoon had been increasing. The manager told us that three new staff had commenced employment and three more were awaiting disclosure and barring clearance. A revised induction training process had been introduced.

We found there had been improvements made by the home in response to the warning notices we issued.

At the time of the inspection there were 16 people who used the service. We spoke with four people, two visiting professionals and one visitor during our inspection. People told us they liked living at the home. One person who had recently arrived at the home was very happy to be there. They told us that staff at the home were very nice and they were settling in well.

People were asked for their permission before any task or activity was undertaken and people’s nutritional needs were met. We observed good support from staff towards people who used the service. However, the processes of assessing and monitoring people’s needs were not robust.

We spoke with thirteen members of staff. All the staff we spoke with told us they loved working at the home. Staff raised concerns with us about the levels of staffing in the home.

We looked at staff records and saw there was programme of mandatory training, supervision and appraisal for staff. We found that people were at risk because staff training was not up to date. All the staff that we spoke with told us they did not feel listened to by the manager. All staff felt supported by the team leader.

We looked at the standard of record keeping in the home. There had been some improvements since our last visit. However, there continued to be inconsistencies in the care plans.

We reviewed the training undertaken by the registered manager and found that the home’s mandatory training requirements had not been met.

During our inspection we spent time reviewing records and talking to staff to ensure that the compliance actions identified at our last inspection had taken place.

We spoke with three members of staff who told us that things had been improving. One care worker told us, “I love to coming into work.” Another said, “We try our very best for the people living in the home, making them happy is what it's all about.”

One person that we spoke with told us, “Everything is all right.” We observed that care provided in the home was caring and respectful.

We found that staff were aware of ways to protect and keep people safe from abuse. There were policies in place and staff understood their responsibilities for observation and reporting. There were no safeguarding incidents to report.

We found that improvements had been made to the storage and administration of medications.

We found that training for staff was being monitored and training sessions were being planned.

We found that care plans had been updated and risk assessments had been reviewed.

There were some inconsistencies in the record keeping which could place people using the service at risk.

People told us that they were well cared for and that the staff met their needs and they received the care and treatment they expected to have. We spoke with five people during the inspection. They told us they were happy with the standard of accommodation, food and cleanliness of the home. One person told us that activities were provided for them and they could participate in them if they wished. A resident’s community meeting enabled people to make decisions and some people had recently been to a Chinese restaurant for a meal which they told us they had enjoyed. Another person told us that their bedroom “feels like mine”.

We spoke with six people who used the service.

One person we spoke with said “Look at these bandages on my legs the nurse came and did them weeks ago. She should have come back a week later and taken them off”.

Another person said “They have put charts up on the bedroom doors, there is no need for it, I do not want a chart on my door”.

People told us that the environment had improved since our last inspection in October 2011. One person said “You should see the new carpet in the lounge”. Another person said “I have moved bedrooms into one that has been decorated and has all new furniture”. Another person said “We now have a window cleaner”.

Some people told us that there was a good choice of food. However, one person said “I am a vegetarian, I don’t get a choice, I just eat what they give me”.

People told us that they liked living at The Hurst even though they knew that things were not right in the home.

One person said “I am not treated very well, staff threaten me to make me go downstairs. I use to go on holiday two years ago but for one reason or another I don’t go anymore”.

People told us that they thought there was a lack of staff saying, “There are only two care staff on every day, a cleaner and the cook”. One person said “I am here in my room all day on my own, they give me my meals and then they go, there is never anyone around”. Other comments included “It’s not right, there are only two night staff on duty and I got up last night to go for a cigarette, night staff would not let me go down to the smoke room. They were just lying on couches not doing anything”.

People told us that they were not happy, as they were not receiving their pocket money on a Monday. One person said “I am always telling the governor what is going on, I have just been to see him about my pocket money which I should have had yesterday. I want it today as I want to go out shopping”. Other comments received were “I need my pocket money, I should have had it yesterday and I need it today to buy my cigarettes”.

People told us that there was a good choice of food. One person said “It’s terrific”. Other comments included “Food is very good”. However, one person said “I have to buy my own pepper and mustard as they never seem to have it here”.

People told us “It is really dark in here we can’t see out of the windows”. Other comments received were “I have lived here for years and I have never seen a window cleaner in all that time, the care staff do it".

We inspected The Hurst Residential Home on 21 and 23 February 2015. This was an unannounced inspection. The first day of the inspection took place at the weekend following receipt of information of concern about weekend staffing. The home was last inspected in May 2014, no concerns were identified at that time.

The Hurst Residential Home is registered to provide accommodation and support for people who experience mental health difficulties including depression, anxiety and personality disorders. The home can provide care and support for up to 29 people. There were 18 people living at the home during our inspection. Accommodation is provided over two floors with communal lounge and dining areas.

A registered manager was 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 and associated Regulations about how the service is run.

Most people spoke positively about the service and commented they felt safe at the home. Our own observations and the records we looked at did not always reflect the positive comments people had made.

People’s safety was compromised in a number of areas. Risk assessments were not always in place where needed. They did not always address people’s changing needs or provide sufficient information for staff to support people safely. Medicines were not administered as prescribed. A lack of process and control of medicines greatly increased the risk and occurrence of errors. Staffing levels did not meet the number the home had assessed as required and some staff recruitment processes were omitted. Incident and accident information was not used proactively or always taken into account when reviewing risk assessments.

The provider was not meeting the requirements of the Mental Capacity Act (MCA) 2005. Mental capacity assessments were not completed in line with legal requirements and staff were not following the principles of the MCA. We found restrictions imposed did not consider whether people could consent to these measures or if a less restrictive practice could be used. Applications for Deprivation of Liberty Safeguard authorisations were not made where needed.

Mandatory training, and other training identified as appropriate, had not been delivered to some staff. Where people needed support or would have benefitted from adapted cutlery or crockery to eat, it was not provided.

There were some positive aspects of care at the service. People gave a mixed response, but were mainly complimentary about the caring nature of the staff. Staff interactions demonstrated they had built rapports with some people and people responded to this positively. Most people and visitors told us staff were kind and compassionate and respectful. However, we found some interactions were task led and other practices did not promote people’s privacy and dignity. It was not clear that people were actively involved in the planning of their care. Some people told us, and we observed, that there was a lack of meaningful activities and structure to people’s days.

People were able to see their friends and families as they wanted. There were no restrictions on when people could visit the home. Visitors we spoke with told us they were made welcome by the staff. Feedback was regularly sought from people, relatives and staff although some people and visitors were unaware of this process.

Although a quality assurance framework was in place, it was ineffective. This was because it did not provide adequate oversight of the operation of the home. The home had not met regulations and there was no management plan to drive forward improvements to the quality of the service provided.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. We are taking enforcement action against Hurstcare Limited to protect the health, safety and welfare of people using this service.