The inspection took place on 12 and 13 September 2017 and was unannounced. Weald Hall Residential Home is registered to provide accommodation and personal care for up to 39 older people. The service mainly provides care to people living with dementia. There were 39 people using the service at the time of the inspection.

At our last inspection on 21 September 2016 the overall rating for this service was Requires Improvement. Three breaches of Regulation of the Health and Social Care Act 2008 (Regulated Activities) 2014 were identified. This was because quality assurance audits had not identified a range of areas that needed to be improved. This included individual risks assessments not always being representative of people’s current need and ineffective systems to prevent harm and abuse. The registered provider sent us an action plan detailing the improvements they would make. They kept us informed of their progress.

There was a new manager in post whose application to the Care Quality Commission for registration was in progress at the time of our inspection.

At the previous inspection on 21 September 2016, the registered provider had not analysed or reported some safeguarding incidents to ensure the safety of the people involved, at this inspection improvements were seen.

Staff knew how to recognise signs of abuse and how to raise an alert if they had any concerns. Risk assessments guided staff to promote people's comfort, nutrition, skin integrity and the prevention of pressure damage and were reflective of people’s needs. Emergency procedures were in place in the event of fire.

People's medicines were stored and managed safely. Where an error had been identified, appropriate action was taken.

There was a system of monitoring checks and audits to identify the improvements that needed to be made. The manager and the operations manager acted on the results of these checks to improve the quality of the service and care.

There was a sufficient number of staff deployed to consistently meet people's needs and respond to call bells in a timely manner.

People received support from staff that were trained and supported to provide appropriate care. People received support to have food and drinks that met their nutritional needs and personal preferences. Support was available to people to ensure their health needs were met in a timely way.

The provider was meeting the requirements of the Mental Capacity Act (MCA) 2005. Mental capacity assessments were completed in line with legal requirements. Deprivation of Liberty Safeguards had been requested for those that required them. 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 provider, manager and staff had an understanding of their responsibilities and processes of the MCA 2005 and DoLS.

Staff cared for people in a caring and sensitive manner and people and their relatives were complimentary about the staff that supported them.

People and their relatives knew how to raise any concerns they had and there were systems in place to gather the views of people to ensure they were happy with the service they received.

The inspection took place on 21 September 2016 2016 and was unannounced. Weald Hall Residential Home is registered to provide accommodation and personal care for up to 39 older people. The service mainly provides care to people living with dementia. There were 35 people using the service at the time of the inspection.

Weald Hall was inspected in January 2015 and was rated inadequate. A further inspection was undertaken in July 2015 and as the service was rated as inadequate, it was placed in special measures. We undertook a responsive inspection in October 2015 to follow up on a number of the requirements that we had made and we continued to have concerns about the governance and the levels of oversight and placed a condition on the provider's registration requiring them to undertake more comprehensive audits and to provide regular updates to the Care Quality Commission (CQC). We undertook a fully comprehensive inspection on 16 March 2016 and we found some improvements, however, there were continued concerns about leadership and a failure to ensure that people were protected from risks.

At this fully comprehensive inspection we found further improvements had been made however, we identified that a number of safeguarding concerns that had not been reported to the Local Authority safeguarding team and subsequently related notifications were not sent to the Commission as required as part of the regulations.

Some people’s risk assessments were not reflective of their current risks and did not guide staff on how to keep people safe.

Most people’s privacy and dignity was respected and promoted but we saw examples of where this was compromised.

The service’s quality assurance system was not robust enough to identify shortfalls. Further improvements were required to ensure the quality of the service continued to improve.

People were supported to maintain good health and had access to appropriate services which ensured they received on going healthcare support. However, measures to monitor people who were at risk of dehydration and malnutrition were not effective.

The service had a manager in post that was in the process of registering with the Care Quality Commission to manage the service. Like registered providers, they are `registered persons`. Registered persons have legal responsibilities for meeting the requirements in the Health and Social Care Act and associated regulations about how the service is run.

Medicines were stored securely and records completed accurately.

Staff were recruited safely and pre-employment checks were in place prior to staff starting employment.

People and their family members were happy with the overall care that they had received.

Staff were supported to meet the needs of the people who used the service.

The Deprivation of Liberty Safeguards (DoLS) were understood by staff and appropriately implemented.

People told us they received care that met most of their needs. Care plans included people's likes and dislikes, however reviews did not always pick up all changes to people's care and support.

The service employed an activities coordinator so people's social and recreational needs were met.

The service regularly sought feedback from people using the service and their relatives to inform where improvements were required.

The inspection took place on 08 March 2016 and was unannounced. Weald Hall Residential Home is registered to provide accommodation and personal care for up to 39 older people. The service mainly provides care to people living with dementia. There were a total of 38 people using the service at the time of the inspection.

Weald Hall was inspected in January 2015 and was rated inadequate. A further inspection was undertaken in July 2015 and as the service was rated as inadequate it was placed in special measures. We undertook a responsive inspection in October 2015 to follow up on a number of the requirements that we had made. At our inspection in October 2015 we continued to have concerns about the governance and the levels of oversight and placed a condition on the provider’s registration requiring them to undertake more comprehensive audits and to provide regular updates to the Care Quality Commission (CQC). At this follow up inspection we found some improvements however, there were continued concerns about leadership and a failure to ensure that people were protected from risks.

The service did not have a registered manager, although an acting manager was in post. We had not received an application for registration. 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.

The Provider had systems in place to ensure that the staff they recruited were properly vetted. Staffing levels were adequate although staff were busy and task orientated in their approach towards people who used the service. Staff did not always recognise some incidents as safeguarding although they knew what the reporting mechanism were.

Risks were not always managed in a proactive way. Medicines were appropriately stored but staff were not always administering in line with how they were prescribed.

Staff were trained but did not always put their training into practice and therefore the training was not effective. We observed examples of poor practice in relation to infection control and safe moving and handling.

Relationships between people living in the service and staff were positive. Staff were caring and kind. There were some activities in place which people enjoyed. While most staff knew people well, the care planning process did not promote personalised, quality care. We observed that people did not look well-groomed and we were not confident that people’s needs were met in an individualised way.

The provider was visible and staff told us that they were well supported. The concerns which were identified at this inspection however had not been identified by the registered person through the auditing process. We had concerns about the care of individuals whose needs were more complex and we were not confident that the homes management had the knowledge to meet these individuals’ needs or recognised some care practices as poor or outdated.

We found that there were a number of breaches in the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and you can see what action we have told the provider to take at the back of the full version of the report.

The overall rating for this service is ‘Requires Improvement’. However, the service remains in 'Special Measures'. We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services 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 month

We carried out an announced comprehensive inspection of this service on 28 and 29 July 2015, at which breaches of legal requirements were found. These included concerns about how staff were trained and how they supported people with their mobility, health and nutrition. Medication was not always safely managed and there was a lack of understanding about consent. People told us that their complaints were not always responded to and there were limited processes in place to assess and monitor the quality of the service.

After the comprehensive inspection, the provider wrote to us to say what they would do to meet the legal requirements in relation to the breaches of regulation. We undertook a responsive inspection on 22 October 2015 to check that they were following their plan and to confirm that they now met the legal requirements in relation to Effective and Well Led.

This report only covers our findings in relation to Effective and Well Led. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Weald Hall Residential Home on our website at www.cqc.org.uk.

Weald Hall Residential Home is registered to provide accommodation and personal care for up to 39 older people. The service mainly provides care to people living with dementia. There were a total of 36 people using the service at the time of the inspection.

The home has a registered manager. 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 our last inspection we found that induction training and support provided was not effective as staff were not suitably skilled and knowledgeable. At this inspection we found that additional training had been provided, and improvements had been made. Staff communicated with people well and had a better understanding of the needs of older people and how risks should be managed. Consistency however remained an issue as the oversight arrangements were not working effectively

At the last inspection we found that the provider did not have appropriate arrangements in place regarding consent. We found that some improvements had been made but staff still had limited knowledge and understanding of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS), which meant that consent was not always fully considered.

At the last inspection we found that people were not protected from the risks of inadequate nutrition and hydration. We found that some changes had been made but staffing levels impacted on the ability of staff to provide the levels of support that people needed.

At the last inspection we found that people’s health needs were not always promoted, and staff were not always clear about how they should support people with specific health conditions such as pressure ulcers and diabetes. We found that improvements had been made and staff were more alert to the risks of deterioration and there were monitoring systems were in place. The arrangements in place would be further strengthened with up to date and clear care plans.

At the last inspection we found that the provider did not have an effective system in place monitor quality and identify, assess and manage the risks. We were told that the provider had started to develop a system but we found that it continued not to be fully operational and therefore we were unable to make a decision about how effective it could be. The concerns which were identified at this inspection had not been identified by the registered person.

We found that there were a number of continued breaches in the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and you can see what action we have told the provider to take at the back of the full version of the report.

The overall rating for this provider remains ‘Inadequate’. This home was placed into ‘Special measures’ by CQC following the last inspection. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.
• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.
• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains 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 the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will 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 we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

We carried out our inspection in response to information of concern received about the care and support provided to people who used the service. At the time of our inspection there were 39 people using the service. As part of this inspection we spoke with seven people using the service, five staff and the registered manager. We also reviewed records relating to the management of the service and to the support needs of people who were using the service. These included six support plans, daily support records and staffing records.

If you want to see the evidence supporting our summary please read our full report. We used the evidence we collected during our inspection to answer five questions.

Is the service safe?

The Mental Capacity Act 2005 (MCA) protects people who lack capacity to make a decision for themselves because of permanent or temporary problems such as mental illness, brain injury or learning disability. If a person lacks the capacity to make a decision for themselves, staff can make a decision in their best interests. Deprivation of Liberty Safeguards (DOLS) must be used if people need to have their liberty taken away in order to receive care and/or treatment that is in their best interests and protects them from harm. The registered manager had a good understanding of the MCA and DoLS. The registered manager told us there were no DoLS in place when we inspected the service. Staff had been provided with the training they needed which would ensure that people were only deprived of their liberty when they needed to be so.

The staff team were skilled and experienced and the staff we spoke with said they thought there were enough staff on duty to enable them to meet people's needs. Staff told us that they received good support from the management team.

Is the service effective?

There was an advocacy service available if people needed it. This meant that, when required, people had access to additional support to help them make decisions.

People's care records showed that care and treatment was planned in a way that was intended to ensure people's safety and welfare. However during our observations we saw that people were not engaged in meaningful planned activities. The registered manager told us that the member of staff who had been employed to plan and facilitate activities had left the service five weeks before our inspection. The registered manager said they were trying to recruit a replacement activities person and that in the meantime care staff were covering this role. Unfortunately we did not see evidence that the service was providing activities for people who used the service. We have asked the provider to tell us how they plan to improve in relation to this.

Is the service caring?

Staff supported and interacted with people in a friendly and patient manner. We saw that staff treated people using the service with respect and showed a good understanding of the aims of the home and how to meet people's day to day needs.

Is it responsive?

Where concerns about an individual's wellbeing had been identified, staff had taken appropriate action that ensured people were provided with the healthcare support they needed. This included seeking support and guidance from care professionals, including doctors and community nurses.

We did not see that any meaningful activities were being provided for people who used the service.

Is the service well led?

The service worked well with other agencies and services to ensure all aspects of people's needs were planned for.

Staff were clear about their roles and responsibilities. Staff had a good understanding of the aims of the home and of the standards of care and support that was expected of them.

During our previous inspection of Weald Hall Residential Home in January 2013, we found that certain minimum standards of quality and safety had not been met. Records showed that staff had not been given clear guidance on how to manage the challenging behaviour of a person who used the service. We also found that minimum staffing levels based on the provider's own policy had not always been met and that people had been living in an uncomfortable environment because the temperature had not been adequately controlled and monitored.

The purpose of our inspection on 6 June 2013 was to check that necessary improvements had been made and that essential minimum standards in other key areas had been met.

During the inspection we saw that new procedures had been put in place to assess, document and manage challenging behaviour. We also saw that a new policy had been introduced to ensure there were enough regular staff on duty at all times to meet people’s needs. We saw evidence that temperatures throughout the home were monitored and checked on a regular basis to maintain a comfortable and safe environment.

People had agreed to and were provided with appropriate levels of care. We also saw evidence that people were provided with a good choice of food and drink in a way that both encouraged and promoted a healthy balanced diet.

Records we looked at showed that the provider had effective systems in place to regularly assess and monitor the quality of services provided.

We inspected the home at 7am. All people at the home were in bed or receiving personal care.

We checked care records and saw people’s personal care needs were being met. We noted that a person with challenging behaviour did not have specific intervention strategies in place to ensure the safety of other people.

We found that areas of the home were cold. We checked the temperature of the dining room where most of the people who used the service would be sitting for breakfast which was planned for 8am. We took a thermometer reading in the dining room that showed the temperature was 56 degrees. We touched the radiators and found two of the four radiators were barely warm to the touch. The remaining two radiators were warm rather than hot to the touch.

We also found that one person's room had a temperature reading of 54 degrees. This meant that people were not living in a comfortable environment and were potentially at risk of hypothermia.

We looked at the staffing rota and found that the provider was not meeting their own minimum staffing level based on the care needs of all the people in the home.

We spoke with two people who used the service. They were able to confirm that they were satisfied with the care they received in line with their wishes. Two relatives spoken with had visited the home over several years. They felt that Weald Hall was, “A good home”. One person spoken with said, ‘It’s lovely here. Staff are always smiling”. Another person said, “You know it’s very good here, don’t you?”

Where people were unable to give informed consent there was evidence of relatives being involved in care and treatment decisions.

We looked at the care documentation for four people who were living at Weald Hall Residential Home. We found that the provider had specific documents on file that had not been signed by people who used the service.

There was evidence that the Registered Manager was fully conversant with the local safeguarding adult procedures.

Care records confirmed that people’s health care needs were met.

We saw staff providing care and support to people living at the home. Staff were unrushed when assisting people. Interactions between people and staff were good natured and relaxed.

There was an effective complaints system available. Two people that we spoke with who lived at the home, and the relatives of two other people told us, they felt able to tell, staff and the Registered Manager if they had a concern or complaint.

During our visit to the home, we spent time talking with people using the service to gain their views about living in the home. Some people, due to their particular needs, were unable to tell us verbally about their experience of living at the home, so observation was an important part of our visit.

People told us they were generally content living in the home, they liked their bedrooms, the food was good, they chose what to eat, they had their health needs met, and had the opportunity to participate in a number of activities of their choice.

People informed us they received the care and support they wanted and needed. They told us staff listened to them and were approachable. People we saw looked relaxed, they smiled and laughed, looked well cared for and participated in a number of activities.

One person using the service told us, “It is ok here; I can talk to my key worker.”

In addition to this another person using the service said, “Staff are ok. Staff help me to get washed and dressed, I have a key worker, who helps me. ”

People told us that they liked the food and always had a choice of what was available.

People told us that they did not have any complaints and that they are supported to maintain regular contact with their families.

The inspection took place on 28 and 29 of July 2015 and was unannounced. Weald Hall Residential Home is registered to provide accommodation and personal care for up to 39 older people. The service mainly provides care to people living with dementia. There were a total of 38 people using the service at the time of the inspection.

We last inspected the service in January 2015 and we rated the service as inadequate as the provider was not meeting the legal requirements. Following the inspection the provider wrote to us to say what actions they intended to take.

The service has a registered manager, although they were not present during the inspection as they were on holiday. 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 this inspection we found that the provider had made some improvements but had not met all the requirements made at the previous inspection.

At the last inspection we found that the environment was not being properly maintained and equipment was not safe. We found that the provider had undertaken some refurbishment and had developed areas for people with dementia to use, which reflected good practice. However we found that people continued to be at risk of unsafe care as staff were not sure how to use some of the equipment provided. Moving and handling practice placed people at risk of injury. Risks were not always well managed, and there had been insufficient consideration of the least restrictive way of keeping people safe. Bedrails were in regular use but the dangers that they presented had not been fully considered.

Infection control was not well managed and this placed people at risk and the staff were not clear about the procedures to follow to protect people from the spread of infection.

At our last inspection we found that induction training and support provided was not effective as staff were not suitably skilled and knowledgeable. At this inspection we found that some training had been provided, however in areas such as infection control and moving and handling the limited skills and knowledge of staff remained an issue.

At the last inspection we found that the provider did not have appropriate arrangements in place regarding consent. We found that some improvements had been made but staff still had limited knowledge and understanding of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS).

At the last inspection we found that people were not protected from the risks of inadequate nutrition and hydration. We found that some changes had been made but the support for people with complex needs was not always effective and provided in line with professional advice. People’s health needs were not always promoted, and staff were not always clear about how they should support people with specific health conditions such as ulcers or diabetes and reducing risks of deterioration.

At the last inspection we found that people did not always have their dignity, privacy and independence promoted. At this inspection we found that some improvements had been made, but some staff continued to treat people in a way which did not promote a respectful and caring approach.

People had their care needs assessed and we saw that staff had started to compile social history’s. These were at an early stage of development and had not yet been incorporated in care plans. Plans were not person centred and did not offer clear guidance to staff about how care should be provided. Our observations were that the plans were not reflective of the care that was provided.

Complaints were not managed in a proactive way or used as a tool to develop care practice.

At the last inspection we found that the provider did not have an effective system in place monitor quality and identify, assess and manage the risks. We saw that the provider had started to develop a system but it was not fully operational and therefore we were unable to make a decision about how effective it could be. The concerns which were identified at this inspection had not been identified by the registered person.

Medicines were appropriately stored but staff were not always administering them safely or in line with how they were prescribed.

At the last inspection we found that there were not adequate arrangements in place that ensured people were engaged in stimulating activities which promoted their wellbeing. We found that improvements had been made in this area and people enjoyed the activities provided.

The Provider had systems in place to ensure that the staff they recruited were properly vetted. Staffing levels were adequate although they were busy and task orientated in their approach. Staff were clear about how they should respond to concerns and safeguarding.

We found that there were a number of breaches in the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and you can see what action we have told the provider to take at the back of the full version of the report.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.
• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.
• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains 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 the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will 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 we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.