About the service: Watford House Residential Home provides accommodation to older people living with dementia. The care home is made up of one three storey building compromising two units. It is registered to provide care for up to 43 people. At the time of our inspection visit there were 36 people living at the home.

People’s experience of using this service:

• Changes had been made to the quality assurance process, however, further improvements were required to ensure people received effective care.

• Some people's care plans had not been updated following changes to their care needs.

• There were gaps in staff training and staff had limited understanding of some important issues, such as ensuring people’s legal rights were upheld in accordance with the Mental Capacity Act 2005.

• People's preferences were not always considered when they were supported to engage in activities and there were limited activities to stimulate people.

• People felt safe using the service.

• Staff recognised the risks to people’s health, safety and well-being and understood how to identify and report abuse.

• People had access to support from staff when needed.

• Staff recruitment processes included a check of their background to review their suitability to work at the service.

• People received support with the medicines. Regular checks were undertaken to ensure people received the correct medicines by staff who were competent to support them.

• Staff understood and practised infection control techniques and had access to protective equipment to promote this.

• People were supported to have enough to eat and drink to maintain their well-being.

• People were supported to obtain advice from healthcare professionals, which was incorporated into people’s care.

• Staff understood the importance of supporting people with empathy and compassion and provided reassurance when people became anxious.

• People and those important to them, were involved in planning their care with support.

• People and their families understood how to complain if they wanted to.

• There had been staffing changes since our last inspection, including new senior management. Staff were positive about the changes and improvements to the service.

• The registered manager was open and honest, and worked in partnership with outside agencies to improve people’s support when required.

More information is in the full report.

We identified a breach of the Health and Social Care Act (Regulated Activities) Regulations 2014 relating to good governance. Details of action we have asked the provider to take can be found at the end of this report.

Rating at last inspection: At the last inspection the service was rated Requires Improvement (report published 9 June 2017).

(For more details, please see the full report which is on the CQC website at www.cqc.org.uk)

Why we inspected: This was a planned inspection based on the rating at the last inspection.

Follow up: We have asked the provider to send us an action plan telling us what steps they are to take to make the improvements needed. We will continue to monitor information and intelligence we receive about the service to ensure good quality is provided to people. We will return to re-inspect in line with our inspection timescales for Requires Improvement services.

This inspection was unannounced and took place on 11 April 2017. Watford House Residential Home is registered to provide accommodation with personal care support for up to 43 people. People who used the service had physical health needs and/or were living with dementia. At the time of our inspection, 40 people were using the service.

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.

Our last inspection visit took place on 7 July 2016. At this time, we found there were breaches in regulations and we issued two requirement notices and told the provider to make improvements. These related to risks to individuals not being consistently managed, and actions not taken to minimise these risks. The provider had not notified us about certain incidents relating to people or the running of the home. The provider sent us a report on 30 August 2016 explaining the actions they would take to improve. We also asked the provider to make improvements to ensure people were supported in a dignified way. In addition, the registered manager did not have effective systems in place to monitor and improve the quality of care for people. At this inspection, we found that some improvements had been made, but further improvements were required.

People’s capacity to make decisions had been considered, however this had not been assessed in line with current guidance. They were supported to access healthcare services, but sometimes referrals were not made in a timely manner. People’s preferences were not always considered, and some people were not able to engage in activities that would stimulate and occupy them. People knew how to raise concerns and complaints, but these were not always dealt with as people wished. There were systems were in place to monitor the quality of the service, but these were not always effective.

Risks to people were assessed, monitored and reviewed. Actions were taken to reduce future risks. Staff knew how to recognise and report abuse, and people were safe receiving support. There were enough staff to meet people’s needs and the provider ensured their suitability to work with people. Medicines were administered and stored to protect people from the risks associated with them.

Staff supported people to make choices and gained people’s consent. Staff received an induction and training that helped them to support people. People enjoyed the food and were supported to maintain a balanced diet.

People’s dignity was promoted and their privacy respected. Staff encouraged people to be independent and were caring in their approach. Visitors were made to feel welcome and there were no restrictions as to when they could call. People were involved in the planning of their care and support.

The registered manager understood their responsibilities of their registration with us. People were positive about the management and leadership, and staff felt supported in their roles.

This inspection was unannounced and took place on 7 July 2016. Watford House Residential Home is registered to provide accommodation with personal care support for up to 43 people. People who used the service had physical health needs and/or were living with dementia. At the time of our inspection, 36 people were using the service.

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.

Our last inspection took place on 4 November 2015. At this time, breaches of legal requirements were found in safe care and treatment, and in good governance. We issued two warning notices and told the provider to take action to meet the regulations. We also asked the provider to make improvements in other areas. The provider sent us a report on 12 January 2016 explaining the actions they would take to improve. At this inspection, we found that a number of improvements had been made, but there were further improvements required.

Risks to people who used the service were not consistently managed, and measures had not always been put into place to reduce the potential risks of people falling. Some records had not been reviewed and updated when needed to give staff clear guidance as to how they should support people safely.

People were not always treated in a dignified and respectful manner. Staff were caring in their approach, but the main interaction with people was focussed on offering support or completing a care task.

Effective systems were not always in place to assess, monitor and improve the quality of care and the provider had not always notified us of reportable incidents that had occurred.

Since our last inspection, we saw that improvements had been made to ensure some risks were managed more effectively to keep people safe. Medicines were managed safely and the environment had improved to reduce the risks of infection for people and staff. People told us they felt safe and staff were aware of how to protect people from abuse and harm. There were enough staff to keep people safe and meet their needs and the provider had safe recruitment processes in place.

We also found there were improvements with the training and support that staff received to meet people’s needs effectively and carry out their roles. People received food and drink that met their nutritional needs and were referred to other healthcare professionals to maintain their health and wellbeing.

People were supported to make decisions. When people were not able to make decisions for themselves, care and support was provided in their best interests. When people were restricted, the necessary authorisations were in place.

People were encouraged to be as independent as they could be and there was increased involvement for people and their families to be involved with the planning of their care. Staff knew people well and were aware of their preferences, and they encouraged people to participate in activities.

Feedback about the service was being encouraged and people felt confident they could raise any concerns with the registered manager.

People spoke positively about the management and leadership, and the provider was developing the management structure within the service to provide more managerial support. The registered manager and provider were keen to make further improvements within the service.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and a breach of the Care Quality Commission (Registration) Regulations 2009. You can see what action we told the provider to take at the back of the full version of the report.

This inspection took place on 4 November 2015 and was unannounced. Watford House is registered to provide accommodation and personal care for up to 43 people. Some of whom were living with dementia. At the time of this inspection 36 people used the service. The last inspection was completed in March 2014 and was compliant with the Regulations we looked at. These included Regulation 9 care and welfare of people, Regulation 14 nutritional requirements, Regulation 12 infection control, Regulation 18 staffing and Regulation 17 records.

Since the last inspection there had been a change in the management arrangements of the service in that the registered manager had resigned the position. A person had been recruited for the manager’s position but has not been registered with us. They told us an application to register would be submitted shortly. 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.

Risks to people’s health and wellbeing were not consistently identified, managed and reviewed and people did not always receive their planned care. People were not always kept safe and their welfare and wellbeing was not consistently promoted because risk assessment and care plans were not consistently followed.

Medication systems, administration and storage were unsafe. People were at risk of not receiving their prescribed medication when they needed it or in the correct way.

Some staff were unsure of the actions they needed to take if they had concerns regarding people’s safety. Incidents were not identified as potential abuse; they were not reported or investigated.

Staff did not receive the required training or supervision they needed to support people with their care needs. Infection control was compromised by staff working practices. Some equipment was unsuitable and incorrectly used and areas within the environment were unhygienic which posed a risk of harm for people.

CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLs) and to report on what we find. There were restrictions of movement in place as people could not access all areas within the home with ease.

People had access to healthcare professionals but did not always receive medical support and interventions in a timely way to ensure their health and well-being was upheld.

People’s care was not personalised and did not reflect their individual needs and preferences. Recreational and leisure activities were arranged throughout the week. Some people were given the opportunity to participate in the group activities if they wished to do so. However most people spent long periods of time with little or no stimulation. People were not treated with the dignity and respect.

The provider did not have effective systems in place to assess, monitor and improve the quality of care. Poor care was not being identified and rectified by the provider.

The provider did not inform us of reportable incidents that occurred at the service. This meant we were unaware of incidents, for example injuries and safeguarding concerns that had occurred within the home.

People were aware of the complaints procedure and knew how and to whom they could raise their concerns. Staffing levels were sufficient to provide basic care and support to people.

The provider had a recruitment process in place. Staff were only employed after all essential pre-employment safety checks had been satisfactorily completed.

We found several breaches of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and a breach of The Care Quality Commission (Registration) Regulations 2009.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’.

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 improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

 You can see what action we told the provider to take at the back of the full version of the report.

When we completed our last inspection of this service in September 2013 we found that the service was not compliant with all the regulations. We identified concerns with the care people received, the management of mealtimes, the cleanliness of the home, staffing levels and record keeping. We carried out this inspection to check the progress the home had made to address these concerns.

People we spoke with were happy with the care they received. One person told us: “I am very happy with the care. I haven’t been well and staff made sure they called the doctor. I am having some treatment”. People were well supported when having their care needs met.

We saw changes had been made at mealtimes to ensure that people were supported and encouraged to eat a nutritious diet.

A decision had been made to remove the birds from the home. This decision was made because there was no one available to ensure the birds and their cages were kept clean at all times to prevent the risk of cross infection at the home.

Staffing levels had improved since our last inspection and staff made aware of the availability of bank staff when needed. We found that the manager had added additional tasks to be undertaken by staff at night, which could impact on people not having their care needs met in a timely manner. The manager planned to monitor this.

We saw that improvements had been made to people’s care records to ensure that they reflected people’s current care needs and the care provided.

At our last visit to Watford House we found that the service was not compliant in one key outcome area. We found that the manager had taken action to improve the care records. We saw that further improvements were needed.

Our visit at Watford House was unannounced. At the time of our visit there were 30 people living at the home. During our visit we spoke with five people and six visiting relatives. We spoke with nine members of staff, which included care staff, cleaning staff and the cook. We spoke with a health professional who visited the home to provide care and treatment for two people.

We looked at anonymous concerns we had received about the service. These related to the care of people in the home and staffing levels. One person told us, “I feel that the level of care has decreased”. We found that there were some omissions in meeting people’s care needs. We observed at our visit that there were identified times when there were insufficient staff to meet people’s needs.

We observed positive interactions between staff and the people who lived there.

We saw that mealtimes needed to be managed better so that people were suitably supported to maintain their nutritional needs.

We saw that improvements were needed to ensure that people were protected from the risk of cross infection.

We visited Watford House Care Home on 12 February 2013. Our visit was unannounced which meant no one who lived or worked there knew we were coming.

During our visit we spoke briefly with most of the 39 people living at the home. We had longer conversations with six people living at the home. The owner was at the home at the time of our visit. We spoke with the owner and four members of staff.

Due to the varied needs of some of the people that lived at the home we were not always able to obtain their personal opinions about the home. To help us understand people’s view of their day to day lives we used a number of methods such as reading records and conversations with relatives.

One of the people we spoke with told us, “I am very happy living here. It has helped me to stop worrying”. Another person told us, “The staff are very helpful and kind to me”.

A relative we met told us that they were very happy with the care their family member received. They spoke highly of the staff and described them as kind and caring.

We saw that there were safeguarding procedures in place. Two care staff we spoke with had a very good knowledge of the procedures. Both staff told us that they had received training in this subject.

We found that the service had systems in place to monitor the quality of the services provided to people living at the home. We saw that improvements could be made to care plan documentation to ensure that they reflected the care people received.

During our visit on the 27th January 2012 we spoke with seven residents, two relatives, five members of staff and the registered manager.

People who use the service told us they were comfortable and had no complaints about the service. One person we spoke with commented “it’s a nice place". People told us staff were very good and they could approach them if they had a concern.

People we spoke with said there were activities they could be involved in such as

painting, knitting and playing bingo. People commented they were able to decide on what activities they took part in.

People told us the food was good and they had choice, one person told us they were offered regular tea and biscuits in between meals which they enjoyed.

The relatives we spoke with on the day said they were happy with the care and staff kept them informed of changes. One relative told us they were aware of how to raise a complaint if they needed to.

We saw good interactions between staff and people living at the home, people were

treated kindly and in a respectful manner. We saw staff spending time with people talking to them and making them comfortable. We saw a member of staff using a ball game to interact with people and taking the opportunity to talk in a relaxed atmosphere.

Staff demonstrated knowledge about the people they cared for and the importance of good health.

We saw the environment to be clean, tidy and safe. People appeared to be presented well with there personal care needs met.

We saw evidence of quality assurance systems that ensured monitoring of general

health and safety. We found management using new ways to improve the quality of life for people living at Watford House.

We found staff were given training and development opportunities and this was reflected in what staff told us.

We saw records reflected the care that people needed and found to be consistent with what people experienced. During our visit we found overall people living at Watford House experienced a good standard of care that ensured their needs were met.