The Old Hall Residential Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. The home is registered to provide accommodation for up to 25 people, including older people and people living with dementia. On the day of our inspection there were 20 people using the service.

A registered manager was not in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. A new manager had started working at the service in XXXX and was intending to register with us.

This is the fourth inspection carried out by the CQC at the service since August 2015. The standards of care during this time have fallen and at our last inspection we imposed a condition on the provider’s registration preventing them from admitting people to the service. At that inspection the provider had not complied with a warning notice we had issued and we found they were in breach of four regulations of the Health and Social Care Act (Regulated Activities) Regulations 2014, (HSCA) and one regulation of the CQC Registrations Regulations 2009. The service was rated as Inadequate and placed in special measures.

At this inspection we found although the provider had made some improvement to the management of medicines, responding to people’s need for greater mental and physical stimulation and addressed some infection control issues we had raised at our last inspection. They had not complied with other ongoing issues such as the quality monitoring of the service and staff training and supervision. We also found further serious issues of concern and as a result we have been unable to lift the restriction we placed on the provider at our last inspection. The provider was in continued breach of three of the HSCA regulations identified at the previous inspection and in breach of a further HSCA regulation.

The risks to people’s safety were not always assessed and appropriate measures were not in place to reduce the risks to people’s safety. This had resulted in increased falls and unplanned weight losses for some people who lived at the service. Staffing levels did not always meet the needs of people at busy times. People were protected from potential abuse as safeguarding issues were dealt with appropriately by staff who understood their roles and responsibility toward the people in their care. Medicines were managed safely and people were protected from the risks of cross infection.

Staff were not supported with appropriate training for their roles and they were not receiving supervision in line with the provider’s own policy. People’s needs were assessed using nationally recognised tools but the assessments were not always used to guide staff to provide effective care. People’s nutritional needs were not always well managed. People had not always been referred to appropriate health professionals to manage their health needs.

People were not supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible; the policies and systems in the service did not support this practice. The environment people lived in was well maintained. However, although there had been improvement to the outside of the building people were still not able to access the outside areas if they chose to as they were not safely enclosed.

Details of people’s specific preferences, choices and views were not always recorded in their care plans. People were supported by a staff group who were caring, and treated them wit

The Old Hall Residential Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. The home is registered to provide accommodation for up to 25 people, including older people and people living with dementia.

We carried out a first comprehensive inspection of the home in August 2015. At this inspection we found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (HCSA). This was because there were shortfalls in the monitoring of service delivery. We rated the service as Requires Improvement.

In January 2017 we undertook a second comprehensive inspection. We found the quality of service had deteriorated and people were not receiving the safe, effective, responsive and caring service they were entitled to expect. We found six breaches of the HSCA. This was because the registered provider had failed to properly assess and mitigate risks to people's safety; staffing levels were insufficient; staff did not always respect people's privacy and dignity; people's legal rights under the Mental Capacity Act 2005 were not fully protected; people did not receive person centred care that met their needs and personal preferences and the registered provider had failed to establish systems and processes to assess, monitor and improve the quality of the service. We also found one breach of the Care Quality Commission (Registration) Regulations 2009.This was because the registered provider had failed to notify us of issues relating to the safety and welfare of people living in the home. Following our inspection, we issued a Warning Notice requiring the registered provider to be compliant with the requirements of the HSCA Regulation 17 – Good governance by 31 July 2017. The rating of the service remained as Requires Improvement.

We conducted this third comprehensive inspection of the home on 5 and 7 December 2017. The inspection was unannounced. There were 25 people living in the home on the first day of our inspection.

At this inspection we found the registered provider had not achieved compliance with our Warning Notice and was in continuing breach of four of the seven breaches of regulations identified at our previous inspection. This was because the registered provider was still failing to properly assess and mitigate risks to people's safety; to respond effectively to people’s need for greater mental and physical stimulation; to notify us of significant incidents and to assess, monitor and improve the quality of the service. We also found one further breach of the HSCA. This was because of the registered provider’s continuing failure to ensure all staff had the training and supervision necessary to support people safely and effectively. In areas including medicines management, the provision of mental and physical stimulation and organisational governance the registered provider had failed to secure the necessary improvement for three consecutive inspections.

The overall rating for the home is 'Inadequate' and the home is therefore in 'Special Measures'.

We have taken action against the registered provider to ensure that they make the necessary improvements to become compliant with legal requirements. You can see details of the action we have taken at the back of the full version of this report.

In some areas the registered provider was meeting people’s needs.

Staffing levels had been increased and were sufficient to meet people's care and support needs; action had been taken to improve the promotion of rights to privacy and dignity and staff reflected the requirements of the Mental Capacity Act 2005 in their practice. Although further work was required in each of these areas, legal requirements were now met.

Staff worked well together in a mutually supportive way an

The Old Hall Residential Care Home is registered to provide accommodation and personal care for up to 25 older people, people with physical disabilities and people living with dementia. At our last inspection in August 2015 we rated the home as Requires Improvement.

We inspected the home on 31January and 6 February 2017. The inspection was unannounced. There were 24 people living in the home on the first day of our inspection.

The home had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers (‘the provider’), 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.

During our inspection we found six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because the provider had failed to properly assess and mitigate risks to people’s safety; staffing levels were insufficient; staff did not always respect people’s privacy and dignity; people’s legal rights under the Mental Capacity Act 2005 were not fully protected; people did not receive person-centred care that met their needs and personal preferences and the provider had failed to establish systems and processes to mitigate risks relating to people’s health, safety and welfare and to assess, monitor and improve the quality of the service.

We also found one breach of the Care Quality Commission (Registration) Regulations 2009.This was because the provider had failed to notify us of issues relating to the safety and welfare of people living in the home.

We have taken action against the registered provider to ensure that they make the necessary improvements to become compliant with legal requirements. You can see what action we have taken at the end of the full version of this report.

We also found other areas in which improvement was required to ensure people received the safe, effective, caring and responsive service they were entitled to expect.

The systems for the induction and training of staff were not consistently effective. Additionally, staff were not provided with supervision in line with the provider’s policy.

At times, staff supported the people who lived in the home in a task-centred way.

In a small number of areas, we found the provider was meeting people’s needs effectively.

The provider had assessed each person’s individual support needs in the case of a fire or other emergency that required the building to be evacuated. There was also an effective system in place to ensure that fire safety and other equipment was serviced regularly in accordance with the manufacturers' instructions and the law.

People were provided with food and drink of good quality that met their needs and preferences and their healthcare needs were supported through the involvement of a range of professionals.

People and their relatives were comfortable raising any concerns with senior staff and formal complaints were rare.

CQC is required by law to monitor the operation of the Mental Capacity Act, 2005 (MCA) and 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, the provider had sought a DoLS authorisation for three people living in the home and was waiting for these to be assessed by the local authority.

The inspection took place on 12 August 2015 and was unannounced.

The Old Hall Residential Care Home is located in the small village of Halton Holegate. It is registered to provide accommodation and personal care for 25 people some of who may be living with a dementia. There were 18 people living in the home on the day of our inspection.

There was a registered manager at the home. 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.

There was a breach in relation to the systems around good governance. Systems in place to identify, monitor and improve the quality of the care provided and to reduce the level of risk in the service were not always effective and did not always identify or correct issues. The provider had not updated the fire procedures to take account of a new extension that had been built.

Individual risks to people while receiving personal care were identified and appropriate equipment was in place. Staff knew how to raise concerns if they were worried that a person was at risk of harm and the registered manager worked with the local safeguarding authority to ensure people were safe.

The provider had systems in place to ensure staff were safe to care for people who lived at the home. Staff were kind and caring with the correct skills, training and support to meet people’s needs. At busy times people had to wait for care and there were not enough staff to fully monitor people’s safety.

People received their medication safely. However, care plans did not support staff to use medicines prescribed to be taken as required. In addition, gaps in the medication administration record made it difficult to see if medicine had been administered correctly.

The Care Quality Commission is required by law to monitor how a provider applies the Mental Capacity Act 2005 (MCA) and 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. This is usually to protect

themselves. The registered manager was aware of their responsibilities under the Mental Capacity Act 2005. However, they had not always involved all the relevant people when making decisions in a person’s best interest.

People were supported to access drinks on a regular basis. They were also supported to make choices around their food. However, where people liked to eat with their fingers the information in care plans did not support staff to make appropriate food choices.

People were involved in planning their care, however, care plans did not contain information about people’s lives and other information was not always easy to find There was no set activity schedule and activities only happened if staff had time.

People told us they were happy with the care they received and while they knew how to raise a complaint no one had done so. People were able to feedback their experiences of care and if any changes were needed to the service.

We conducted a Short Observational Framework for Inspection (SOFI) at lunchtime and saw staff interacted with people in a positive and enabling way. People were given a choice of where to sit and what to eat and drink.

We saw people’s bedrooms were personalised and most had items of furniture they had brought from home and photographs of their families on display.

People told us they were well looked after. One person said, “The staff are pleasant and I have a choice of what to do.” Another person said, “They give me a choice and I feel involved. I’m very well looked after.”

We saw people’s needs were assessed and care and treatment was planned and delivered in line with their individual care plan.

We saw all areas of the home were clean. All furniture and equipment was in a good state of repair.

People told us the home was always clean. One person said, “It a very nice home. It’s clean, they keep my toilet clean.”

We saw there was effective recruitment and selection processes in place and all necessary checks had been made prior to staff being appointed into post.

We saw a copy of the complaints policy. Guidance on how to make a complaint was on display in the main reception area. People were made aware of the complaints system.This was provided in a format which met their needs.

The provider had sent us an action plan telling us what they were going to do to make sure they were compliant with the standard we had set a compliance action against when we visited in July 2012. This related to record keeping.

We did not speak with people who used the service. This was because we were mainly checking records and speaking with staff.

Care records had improved since we visited in July 2012 and reflected all the care needs of people in the home. They were reviewed regularly or when changes were needed.

The manager recognised further improvements were needed to the care records to make them easier to follow and prevent duplication.

Due to the complex needs of the people using the service we used a number of different methods to help us understand their experiences. We looked at records which included care plans and minutes of meetings. We also spoke with care staff and a relative.

We also sat and watched care staff delivering care to people in the home. This helped us to understand the needs of people who could not talk with us.

We found that people who could speak with us were respected and involved in their care. One person said, “I like it here and I’m looked after very well.”

Another person told us, “They’re very kind here and I get the help I need.”

Although care staff knew about the needs of people, the care plans did not reflect those needs.

People were complimentary of the food they had and said they always had a choice at mealtimes.

People told us they felt safe in the home and if they didn’t, they felt the manager would do something about it. Care staff knew how to protect the people in the home and who to contact if they had concerns.

We saw evidence that care staff had received training and support to do their jobs

People felt they were asked about their opinions about the running of the home by the manager and felt confident taking any concerns directly to staff members or the manager if needed. The home had quality assurance systems in place to ensure they monitored the quality of service that people received. However, these could have been more robust.

The care plans did not show people's involvement or always reflect people's needs.