Hartwell Lodge Residential Home

Hartwell Lodge Residential Home is a residential care home providing personal care to up to 32 people, some of whom live with dementia. At the time of our inspection there were 30 people using the service.

People’s experience of using this service and what we found

Quality assurance systems had improved since the last inspection and were overall effective in ensuring people received safe and high-quality care. However, we found audits needed improving in relation to topical medicines and Legionnaires. We have made a recommendation about this.

Staff were aware of risks related to people's care and how to support people appropriately. Staff knew how to whistle blow and raise concerns inside and outside of the organisation should they need to.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

There were enough staff deployed to support people with their needs and staff were safely recruited. We were assured the service were following safe infection prevention and control procedures to keep people safe.

The provider had worked hard to make improvements since our last inspection. The registered manager was responsive to feedback given and was dedicated to ensuring people received a safe, person-centred and compassionate service.

People, relatives and staff told us they were given the opportunity to feed back on the service. They were confident the registered manager would listen and act on any concerns. Everyone thought the service was well-led. People were happy living at Hartwell Lodge and staff enjoyed their work. We found the atmosphere to be positive and engaging.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 25 May 2022). A breach of regulation in relation to good governance was identified. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

At our last inspection we recommended that improvements were made in relation to risk management, infection control, medicines, and duty of candour. At this inspection we found the provider had mostly acted on recommendations, although improvement in relation to topical medicines was still needed. Following the inspection, the provider improved their systems around this and we have recommended these are monitored to ensure they can be sustained and embedded into practice.

Why we inspected

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Hartwell Lodge Residential home on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Hartwell Lodge Residential Home is a residential care home providing personal care to up to 32 people, some of whom live with dementia. At the time of our inspection there were 30 people using the service.

People’s experience of using this service and what we found

Quality assurance systems had not always been effective in identifying the concerns we found at this inspection.

Although the registered manager demonstrated an open and honest approach when care did not go to plan, records needed to improve about this. We have made a recommendation about this.

The lack of robust infection control practices placed people at risk of being exposed to infections. We made a recommendation about this.

We also made a recommendation that the provider seeks reputable guidance to ensure the safe management of medicines. This was because discrepancies were found between records and the number of tablets. Records relating to people’s ‘as required’ and topical medicines also needed improvement.

Risks associated with people’s needs and health conditions were effectively assessed, monitored and mitigated although some records relating to risk needed improvement.

Recruitment practices were safe and there were sufficient numbers of staff available to meet people's needs. Staff told us they had enough training to carry out their roles effectively and were well supported.

The service worked well with healthcare professionals to ensure joined up care and good outcomes for people. People were provided with a nutritious and balanced diet that met their needs and preferences.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People were supported by kind and caring staff who respected their privacy and dignity.

A consistent staff team meant they had got to know people well. Staff understood people’s needs and preferences and delivered care accordingly. People took part in activities they enjoyed. People were well supported at the end of their lives.

People were happy living at Hartwell Lodge and spoke positively about the care they received. The service had a positive person-centred culture. People, relatives and staff provided us with positive feedback about the registered manager. They also told us they would recommend the home to others.

The registered manager demonstrated a willingness to make improvements and during the inspection began reviewing their systems and process to ensure the service consistently provided good, safe, quality care and support.

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

Rating at last inspection and Update

The last rating for this service was requires improvement (published 18 June 2019). Breaches of regulation in relation to good governance and a failure to notify were found. We served a Warning Notice in relation to the governance of the service.

We undertook a targeted inspection in September 2019 to check whether the Warning Notice we previously served in relation to Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met. We found the provider was no longer in breach of Regulation 17. The overall rating for the service did not change following the targeted inspection in 2019 and remained requires improvement. We use targeted inspections to follow up on Warning Notices or to check concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

In December 2020, we conducted a review to ensure that the Infection Prevention and Control (IPC) practice was safe and the service was compliant with IPC measures. We found that it was. This was a targeted inspection looking only at the IPC practices the provider had in place. Therefore, the rating of the service at this inspection did not change.

You can read these reports by selecting the ‘all reports’ link for Hartwell Lodge Residential Home on our website at www.cqc.org.uk.

At this inspection we reviewed all five domains. The service remains rated requires improvement and a breach relating to governance was identified. This service has been rated requires improvement for the last seven consecutive inspections. We will describe what we will do about the repeat requires improvement in the follow up section below.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvements. Please see the full details of the report which is on the CQC website at www.cqc.org.uk

You can see what action we have asked the provider to take at the end of this full report.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified a breach in relation to governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice.

• The home had a current outbreak of Covid 19 and were not allowing visits to people living in the home, this was in accordance with latest best practice. However, protocols were in place for all visitors to prevent the spread of infection and prior to the outbreak people were supported to receive visits in a safe way.

• People were admitted into the service safely. They were required to be tested for Covid 19 and isolate in their room for 14 days.

• When people needed to isolate in their rooms, they had been supported to maintain contact with those important to them, through video and phone calls. People had also been supported with additional activities provided by staff in the home to ensure their well-being.

• Comprehensive communication arrangements were in place to ensure people, staff and their relatives were kept up to date about Covid 19 prevention measures and the safety arrangements within the home.

• The provider had made appropriate arrangements to test people and staff for Covid 19 and was following government guidance on regular testing. For people who used the service that had a positive Covid 19 test, re-testing was planned to be undertaken 90 days after their positive diagnosis unless people became symptomatic then they would be re tested. This was in line with national guidance.

• Staff had received appropriate training and support to manage Covid 19. Staff had received training on Covid 19, infection control and the use of Protective Personal Equipment (PPE), including the correct way to put on and take off PPE. The deputy manager spoke very positively about the hard work and dedication staff had shown throughout the pandemic.

• The premises were clean, hygienic and well ventilated. Additional cleaning schedules had been introduced since the beginning of the coronavirus pandemic. For example, high touch areas such as door handles, and light switches were regularly cleaned throughout the day.

• Hartwell Lodge had clear policies, procedures and contingency plans in place regarding Covid 19 and infection control. Audits were undertaken, and actions were taken to ensure improvements were made. They had kept up to date with current government guidance and communicated changes to staff promptly.

Further information is in the detailed findings below.

Hartwell Lodge Residential Home offers accommodation over two floors for up to 32 people, some of whom are living with dementia or a learning disability. At the time of the inspection the home was providing care and support to 28 people.

People’s experience of using this service and what we found

The provider and the registered manager had taken steps to improve the service and ensured people received safer care. An action plan to address the warning notice carried out by CQC had been implemented. All the requirements of the warning notice had been met.

Quality assurance systems to measure the effectiveness of the service had been improved. The registered manager had a good oversight of the service and monitored the actions needed to improve the safety and quality of the service.

Risk assessments and care plans were up to date and provided guidance to staff about how to support people effectively. Medicine records tallied with the number of tablets counted.

The deployment of staff and improved activities meant people’s emotional and social needs were met. The environment was suitable for the people who lived in the home.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the systems in the service supported this practice.

Notifications about important events were sent to to CQC as required.

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

Rating at last inspection (and update)

The last rating for this service was requires improvement (published 19 June 2019) when there were two breaches of regulation.

Following our last inspection, we served a warning notice on the provider. We required them to be compliant with Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 by 13 June 2019.

Why we inspected

This was a targeted inspection based on the warning notice we served on the provider following our last inspection. CQC are conducting trials of targeted inspections to measure their effectiveness in services where we served a warning notice.

We undertook this targeted inspection to check they now met legal requirements. This report only covers our findings in relation to the governance of the service. The overall rating for the service has not changed following this targeted inspection and remains requires improvement. This is because we have not assessed all areas of the key questions.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

People’s experience of using the service:

•The provider lacked effective governance systems to identify concerns in the service and drive the necessary improvement. At times there was a lack of clear and accurate records regarding people’s medicines, mental capacity, support and any potential risks to them. The provider had not always notified CQC about important events that happened in the service which meant these could not be monitored.

•People told us there were not always enough staff at all times of the day and although we observed staff responded to people’s needs promptly, people did not receive enough stimulation and engagement. We have made a recommendation about this. Activities needed to be more frequent and person-centred to meet people’s social and emotional needs.

•Despite this, most people were happy living at Hartwell Lodge Residential Care Home and people told us they felt safe. People were supported by staff who were kind, caring and who mostly understood their likes, dislikes and preferences. Where they needed external health input they were supported to receive this. People were cared for by staff who were well supported and received appropriate training and supervision to meet people's needs effectively.

•People and their relatives knew the registered manager and felt able to speak to them if they had any concerns. Staff felt well supported by the registered manager and felt they had improved the culture of the service. The registered manager demonstrated a willingness to make improvements and during the inspection began reviewing their systems and process to ensure the service consistently provided good, safe, quality care and support.

Rating at last inspection:

Requires improvement (Report published 18 January 2018)

Why we inspected: This was a planned inspection based on our last rating. At the last inspection the provider was rated as Requires Improvement.

Follow up:

The service has a history of breaching legal requirements. It was rated Inadequate in March 2017. In September 2017 we found improvements had been made but not all legal requirements were met and the service was rated Requires Improvement. At the last inspection in December 2017 all legal requirements were met, however the service was rated Requires Improvement because further improvements were needed to embed the systems in place to ensure a quality service was being delivered. At this inspection the service did not meet all legal requirements and has been rated Requires Improvement.

Because of the history of the service and as this is the third consecutive time this service has been rated as Requires Improvement, CQC will propose to take regulatory action. Full information about the CQC’s regulatory response to the concerns found during the inspection is added to reports after any representations and appeals have been concluded.

The service has a history of breaching legal requirements. Following an inspection in February 2016, the Commission took enforcement action against the provider for failing to meet the requirements of the legislation relating to safe recruitment processes, safe care and treatment of people, person centred care and governance. In addition, requirement notices were issued for failing to ensure people were safeguarded against the risk of abuse or harm; failing to ensure appropriate numbers of skilled and trained staff were available; failing to ensure appropriate consent was sought; failing to ensure complaints were responded to and failing to ensure people were treated with dignity and respect. At this inspection the service was rated overall inadequate and placed into special measures.

We carried out a further inspection in October 2016. Whilst some improvements had been made and the service was rated as overall requires improvement, the key question well led remained inadequate. The improvements made were insufficient to take the service out of special measures. The provider remained in breach of the regulations regarding the safe management of medicines, recruitment, staffing levels and support, gaining consent and governance of the service. Requirement notices were issued and he Commission considered the previously imposed condition remained appropriate.

Following information of concern received in March 2017 a further inspection was carried out. We found serious concerns about the safety of people living at the home. The provider was failing to keep people safe because risks were not adequately assessed and staff did not have the training, skills and knowledge to support them safely. In addition they continued to provide insufficient numbers of staff, they had failed to ensure staff treated people with dignity and respect at all times and their governance system remained ineffective. The overall rating for the service had returned to inadequate and we did not remove the service from special measures. The Commission took enforcement action and cancelled the registered manager's registration.

In September 2017 a further inspection was carried out and we found improvement had been made. Whilst breaches in relation to safe care and treatment and good governance remained these had very little impact on people. The service was rated as overall requires improvement, but the key question well led remained inadequate.

This inspection was carried out to ensure that the improvements found in September 2017 had continued and been sustained. We found significant improvements had been made at this inspection. All legal requirements had been met and no questions were rated as inadequate. Therefore the service has exited special measures.

Merry Hall Nursing and 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. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home accommodates up to 32 older people and some who require nursing care, across two adapted buildings. At the time of the inspection there were 20 people living in the home.

A registered manager was not in post during the inspection. 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. A manager had been appointed and started working in the home approximately four months before our inspection. They had submitted applications to become the registered manager and were awaiting CQC assessment and decision. Throughout the report we refer to this person as the manager.

Further changes had been made to the systems used to monitor and assess the safety and quality of the service. Some of these required review to ensure they were fully effective but the manager was aware of this and planned to look at these during the week of our visit. The provider audits produced clearer action plans which we could see were being acted upon. The manager had a clear plan to develop the service further. They were working well with a clinical governance consultant and had engaged an external company to provide advice on how to make the service more dementia friendly.

Some records needed further work to ensure they were completely accurate. The provider delivered training and ensured support and supervision was in place to enable staff to undertake their roles effectively. However, some staff had not received the training needed to manage choking risks for people.

Staff had a good understanding of the needs of people and worked well as a team. They understood the risks associated with people’s care needs. Medicines were safely managed. People were protected against abuse. The manager and staff recognised their responsibilities and duty of care to raise safeguarding concerns when they suspected an incident or event that may constitute abuse. Systems to ensure staff recruited were of good character were operated effectively and staffing levels were based on individual’s needs.

Staff understood the need for consent and demonstrated the principles of the Mental Capacity Act 2005 were understood and applied appropriately. They ensured people were involved in all aspects of the care and support. Where necessary they involved others such as families to aid the development of clear support plans. Other health professionals were accessed to ensure people’s health care needs were met.

Staff provided compassionate and kind support which respected people’s dignity and privacy. People were very comfortable in the company of staff. Care plans were more person centred and we saw staff responded to people’s changing needs. Activities were based on individual preferences.

Staff were confident that the manager was knowledgeable and would take appropriate action if any concerns were raised. They felt supported and that the manager was easy to approach. The manager operated an open door policy in order to provide clear leadership.

The information shared with CQC about the incident indicated potential concerns about the assessment and management of the risk of choking for people. This inspection examined those risks as well as other areas.

Merry Hall Nursing & Residential Care Home is a registered care home and provides accommodation, support and nursing care for up to 32 people, some of whom live with dementia. Support is provided in a large home that is across two floors. Communal areas include two lounges and a dining room. At the time of our inspection there were 27 people living at the home.

The service has a history of breaching legal requirements. Following an inspection in February 2016 CQC served one warning notice for failing to ensure effective and safe recruitment processes. Due to concerns about the safe care and treatment of people, person centred care and governance CQC also imposed a condition in June 2016 on the provider's registration that required them to audit all people's care plans, risk assessments and medicines on a weekly basis and produce a monthly report for CQC regarding this. In addition requirement notices were issued for failures to ensure safeguarding of people, appropriate numbers of skilled and trained staff, ensuring appropriate consent was sought, ensuring complaints were responded to and for a failure to ensure people were treated with dignity and respect. At the inspection in February 2016 the service was placed into special measures.

At the last inspection in October 2016 CQC found that whilst some improvements had been made these were insufficient to take the service out of special measures. The provider remained in breach of the regulations regarding safe management of medicines, recruitment, staffing levels and support, gaining consent and governance. Whilst we continued to find concerns with the provider’s compliance the condition CQC had imposed required them to take weekly action to make the improvements needed and ensure these regulations were met. CQC considered this condition remained appropriate for breaches of Regulation 12 and 17 of the Health and Social Care Act 2008. Requirement notices for breaches of Regulations 11, 18 and 19 were issued. The provider was required to submit an action plan by 3 January 2017 to CQC telling us how they would meet the requirements of these three regulations; however they did not submit this prior to this inspection.

A registered manager was in place at this inspection. 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 the overall rating for this service is inadequate and we did not find sufficient improvements to remove the service from special measures. CQC are now considering the right regulatory response to address the concerns.

People were not safe because risks associated with their care needs had not been consistently and appropriately assessed and plans developed to mitigate these risks. Where there were plans in place these were not adhered to by all staff at all times. Staffing levels did not meet people’s needs and placed them at risk especially around meal times. Staff had not been given the right skills and knowledge to manage risk and provide effective care. People were not consistently treated with respect. The language used to describe people was degrading as it referred to them as tasks rather than individuals. We made a recommendation that the provider and registered manager review and take action to improve the process of involving people in making decisions about the service.

Medicines management had improved although the provider was introducing a new system for medicines at the time of inspection. As such we were unable to assess the safety and effectiveness of this. Recruitment processes had improved and were now safer. There had been no complaints since our last inspection and the provider had a policy in place and on display.

Consent was sought and the understanding of the Mental Capacity Act 2005 had improved, although the records regarding this were at times confusing and not accurate.

People had access to health professionals when these were requested. They were supported to maintain a balanced diet and additional support was requested when they were found to be losing weight. However, people’s feedback of the food varied and they felt more choice was needed. Some people knew they had a care plan and were involved with this. Care plans varied in detail with some being very person centred and others lacking information needed.

Management support was inconsistent leading staff to feel unable to approach them at times. Quality systems were in place but these were not effective in identifying areas that required improvement. Records remained inaccurate and were not up to date.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. CQC is now considering the appropriate regulatory response to the shortfalls we identified during this and previous inspections. Where providers are not meeting the fundamental standards, we have a range of enforcement powers we can use to protect the health, safety and welfare of people who use this service. When we propose to take enforcement action, our decision is open to challenge by the provider through a variety of internal and external appeal processes. We will publish a further report on any action we take. You can see what action we told the provider to take at the back of the full version of this report.

Merry Hall Nursing & Residential Care Home is a registered care home and provides accommodation, support and nursing care for up to 32 people, some of whom live with dementia. Support is provided in a large home that is across two floors. Communal areas include two lounges and a dining room. At the time of our inspection there were 19 people living at the home.

The service has a history of breaching legal requirements. Following an inspection in February 2016, the Commission served one warning notice for failing to ensure effective and safe recruitment processes. Due to concerns about the safe care and treatment of people, person centred care and governance, the Commission also imposed a condition on the provider's registration that required them to audit all people's care plans, risk assessments and medicines on a weekly basis and produce a monthly report for the Commission regarding this. In addition, requirement notices were issued for failing to ensure people were safeguarded against the risk of abuse or harm; failing to ensure appropriate numbers of skilled and trained staff were available; failing to ensure appropriate consent was sought; failing to ensure complaints were responded to and failing to ensure people were treated with dignity and respect. At this inspection the service was rated overall inadequate and placed into special measures.

We carried out a further inspection in October 2016. Whilst some improvements had been made and the service was rated as overall requires improvement, the key question well led remained inadequate. The improvements made were insufficient to take the service out of special measures. The provider remained in breach of the regulations regarding the safe management of medicines, recruitment, staffing levels and support, gaining consent and governance of the service. Requirement notices for breaches of Regulations 11, 18 and 19 were issued. The provider was required to submit an action plan to the Commission telling us how they would meet the requirements of these three regulations; however they did not submit this in the time specified. The Commission considered the previously imposed condition remained appropriate for breaches of Regulation 12 and 17.

Following information of concern received in March 2017 a further inspection was carried out. We found serious concerns about the safety of people living at the home. The home were failing to keep people safe because risks were not adequately assessed and staff did not have the training, skills and knowledge to support them safely. In addition they continued to provide insufficient numbers of staff, they had failed to ensure staff treated people with dignity and respect at all times and their governance system remained ineffective. The overall rating for this service had returned to inadequate and we did not remove the service from special measures. The Commission took enforcement action and cancelled the registered manager’s registration.

A registered manager was not in place at this inspection. However, the provider had recruited a person to undertake this role and they had started work in the service five weeks prior to our inspection. This person told us they intended to submit an application to become the registered manager for the service. Throughout this report we refer to this person as the 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.

Improvements have been found at this inspection and some previously breached regulations had been met and the home was no longer in breach of these regulations. However, the provider's history demonstrates that they have been unable to fully embed and sustain improvements in the past at this service. The overall rating for this service is ‘Requires improvement’. However, we are keeping the service 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.

Whilst changes had been made to the systems used to monitor and assess the safety and quality of the service, these still required some review to ensure they were fully effective and truly embedded in to practice. We found some concerns about these systems and their ability to fully analyse the service and ensure information for staff was clear so as not to pose any potential risks to people.

Improvements had been made to the assessment of risks to people, to planning the delivery of care to reduce these risks and to ensuing staff had a good understanding of this. However, some areas still required improvement including identifying risks associated with some medicines and the monitoring of some health conditions and pressure relieving equipment.

Staffing levels were sufficient to meet the needs of people living in the home at the time of the inspection; although the system used to identify this was not understood by the management team. Staff had received supervision and additional training since the last inspection which enabled them to understand the needs of people living in the home. The management team were aware of the gaps in the training staff had received and were addressing this. Recruitment process ensured that staff who commenced work in the home were safe and appropriate to work with adults at risk. Staff had a good understanding of safeguarding people and were confident to raise any concerns they had with the manager or externally if they felt this was needed.

People were involved in their care plans however, work was needed to ensure there was always a personalised approach to care planning. They were supported by staff that understood the importance of gaining their consent before delivering care. Staff understood the principles of the Mental Capacity Act 2005 and applied this to their practice. Although staff lacked an understanding of where deprivation of liberty safeguards had been authorised, they consistently described approaches that were least restrictive for people.

People consistently told us how staff were kind, caring and supported their independence. Interactions observed confirmed this. Although people said the food could be repetitive, they all said they enjoyed it. Plans were in place to change the menus and staff monitored people’s nutrition. People had timely access to other professionals when they needed this to ensure their health care needs were met. Records and discussions showed that the service responded to people’s change in needs and requests.

People knew how to complain but all said they had not needed to. There had been no complaints since the last inspection but a system was in place to ensure these were recorded and acted upon.

Everyone we spoke with described the manager in a positive way. They felt the manager was open, approachable and were confident in their ability. They had a clear focus of what they needed to do, although they did not have a formalised plan in place to identify how and when each issue would be addressed.

We found two on-going breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The Commission are considering the appropriate regulatory response to the shortfalls identified during this and previous inspections. Where providers are not meeting the fundamental standards, we have a range of enforcement powers we can use to protect the health, safety and welfare of people who use this service. When we propose to take enforcement action, our decision is open to challenge by the provider through a variety of internal and external appeal processes. We will publish a further report on any action we take. You can see what action we told the provider to take at the back of the full version of this report.

Merry Hall Nursing & Residential Care Home is a registered care home and provides accommodation, support and nursing care for up to 32 people, some of whom live with dementia. Support is provided in a large home that is across four floors. Communal areas include two lounges and a dining room. At the time of our inspection there were 24 people living at the home.

Following an inspection in February 2016 the Commission served one warning notice for failing to ensure effective and safe recruitment processes. Due to concerns about the safe care and treatment of people, person centred care and governance the Commission also imposed a condition on the provider’s registration that required them to audit all people’s care plans, risk assessments and medicines on a weekly basis and produce a monthly report for the Commission regarding this. In addition to the warning notice and the imposed condition, requirement notices were issued for failure to ensure safeguarding of people, appropriate numbers of skilled and trained staff, ensuring appropriate consent was sought, ensuring complaints were responded to and for a failure to ensure people were treated with dignity and respect.

At the last comprehensive inspection in February 2016 this provider was placed into special measures by CQC. This inspection found that insufficient improvements had been made to take the provider out of special measures as they were still rated inadequate in one key question.

There was no 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. A person had been employed to be the registered manager and had started their application process with the Commission. They had only been working as the manager for one week at the time of our inspection.

After the previous inspection in February 2016, we imposed the condition to support and ensure the provider assessed aspects of the service which could pose a risk to people and take appropriate action. However, we were not confident in the systems the provider used to assess these areas as the information the Commission had been provided with as a result of this condition, we found to be inaccurate and not reflective of our findings during this inspection.

Quality assurance systems whilst in place were not fully effective in identifying and remedying shortfalls in a number of key areas.

Some improvements had been made to the management of medicines however despite weekly audits, medicines were not always managed safely. Gaps in recording of the administration of medicines had not been identified and explored and medicines had not been administered despite records saying they had. This had not been identified prior to our inspection.

Some improvements had been made to the recruitment of staff, however these were inconsistent. Appropriate recruitment checks had not always been undertaken and the provider’s policy was not always adhered to. Whilst audits had identified concerns with recruitment records of staff, this had not driven the improvement needed.

Some improvements had been made to the assessment and management of risk associated with peoples care although further work was needed. Care plans had improved although where we found gaps and inconsistencies, the providers weekly audits had not.

People raised concerns about staffing levels and our observations reflected that these did not always meet people’s needs. The deployment of staff did not always ensure suitably skilled and trained staff were on duty because staff had not always received appropriate training, induction and supervision.

Day to day people’s choices were met but the service continued to seek consent from people who did not have the legal authority to provide this. At times capacity assessments were not decision and time specific and best interests decisions could not always be demonstrated. Deprivation of Liberty safeguards was mostly understood and authorised applications were held in people’s care plan folders. We were concerned that one member of staff told us if a person with capacity to make the decision wanted to go out, they would not allow them to go out alone.

Whilst staff did not always understand the term safeguarding, they knew the signs of abuse and the action they should take if they had any concerns abuse may be occurring. We have made a recommendation that the provider review the system used to identify matters that require reporting to the local authority safeguarding team to ensure these are recognised and acted upon promptly.

People’s nutritional needs were met and they described the food as good. Complaints were acted upon and addressed.

People felt staff were kind and caring. Staff demonstrated how they respected people’s privacy and dignity. They spoke kindly and offered support when needed. Staff had a good understanding of people, their needs, likes and preferences.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. CQC is now considering the appropriate regulatory response to the shortfalls we identified during this and previous inspections. Where providers are not meeting the fundamental standards, we have a range of enforcement powers we can use to protect the health, safety and welfare of people who use this service. When we propose to take enforcement action, our decision is open to challenge by the provider through a variety of internal and external appeal processes. We will publish a further report on any action we take. You can see what action we told the provider to take at the back of the full version of this report.

Merry Hall Nursing and Residential Care Home provides accommodation, care and nursing support to older people, some of whom are living with dementia. It provides support for up to 32 people; at the time of inspection 28 people lived in the home.

A registered manager was in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

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.

Serious injuries caused by equipment and an unexplained serious injury had not been reported to external bodies. They had not been investigated by the registered manager meaning people may not have been safeguarded. Risk associated with people’s care were not always appropriately assessed and action was not taken to reduce the risks of harm to people. Where injuries had occurred, assessments of risk had either not been done or not been reviewed to ensure these did not occur again. Staff had not received training to support them with assessing risk and developing plans of care. Medicines were not managed safely because significant medicines errors were not identified and medicine plans for life threatening conditions were not always adhered to.

Thorough recruitment checks were not carried out and where concerning information was provided at the time of recruitment, this had not been explored further, meaning people were not protected because safe recruitment practices did not take place. The system for identifying staffing levels was ineffective and at times observation reflected staff were not always present to meet people’s needs. Some feedback from people indicated staff response time to them was not always prompt.

People spoke positively about the food they received and the choice they were offered, however unplanned weight loss was not always identified and as such no action was taken to explore why this was happening and take action to address this for people. Where people had an identified need their care had not always been developed to ensure these needs were recognised and met. Care plans were not always personalised, accurate and reflective of people’s needs and preferences. Although people could access external healthcare professionals, this relied on prompt staff referrals and good communication which did not always happen.

Observation demonstrated people’s consent was sought before staff provided care. Staff and the registered manager demonstrated a limited understanding of the Mental Capacity Act 2005. The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The service had submitted applications for DoLS for some people living in the home to the supervisory body.

Most observations demonstrated staff were compassionate and kind but some also demonstrated staff became easily distracted while providing support which lead to a lack of respect being shown.

A complaints policy was in place but when these were raised we could not see that these were always investigated, addressed promptly and that there was any learning from them. Systems were in place to gather people’s views and assess and monitor the quality of the service. These were not always fully effective. Notifications were not being submitted as required.

People and their relatives described staff as kind. They said they felt safe and well looked after. They knew how to make a complaint and felt confident these would be listened to and acted upon. Staff felt supported and received an induction when they first started work which helped them to understand their roles and responsibilities. Supervisions had begun to take place and a plan for future training was in place. Staff demonstrated a good understanding of safeguarding people at risk. They were confident any concerns raised would be acted upon by management.

We found 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.

Following our inspection we made a referral to the Local Authority safeguarding team to advise them of concerns we had identified during our inspection. In addition we asked the provider to send an urgent action plan to us outlining how they would address the immediate concerns we had for people. This was submitted promptly and the Local Authority confirmed they were monitoring this action plan.

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

Is the service safe?

People's care plans included information about any risks to people's health, safety and welfare. Records showed risks were assessed and actions identified and carried out to minimise risk. The registered manager reviewed accidents and incidents in the home and took action to prevent reoccurrence. We saw evidence that the environment and care practices were monitored and reviewed to ensure people experienced safe care and treatment.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. At the time of our inspection the provider was introducing a revised assessment to ascertain whether people's needs and mental capacity would require an application for a DoLS. This was in response to a recent Supreme Court judgment. We were assured that a review of people's needs would be completed following our inspection. This meant the provider was taking appropriate action to ensure the human rights of people using the service were protected.

Is the service effective?

People told us they were satisfied with the care they received and felt their needs had been met. It was clear from what we saw and from speaking with staff that they understood people's care and support needs. A person's relative told us how their relative had been supported to make improvements in their health. Another person said "I get as much help as I want; they (staff) listen to me and respect my decisions." Staff had received training to meet the needs of the people living at the home.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers were patient and gave encouragement when supporting people. A person's visitor said "my friend likes to talk about the old days, staff have spent time chatting about their interests and taken them to visit a museum, I think they look after my friend well." One relative said "my relative looks well cared for, I can visit at any time and I have seen nothing to cause concern - on the whole I am very pleased."

Is the service responsive?

People's needs had been assessed before they moved into the home. Records confirmed people's preferences, abilities and desired outcomes had been recorded and care and support had been provided that met their wishes. People's healthcare needs were met by trained nurses in the home and by other healthcare providers as required. Complaints were investigated and responded to and people told us staff listened to them.

Is the service well led?

Quality assurance processes were in place. This helped to ensure that people received a good quality service at all times. Staff we spoke with told us they were well supported by their managers and senior staff. A staff member said, "We can go to any of the managers they all know their stuff." Records confirmed staff were assessed as competent prior to working unsupervised. Records showed people and their relatives were asked for their feedback on the service and their comments were acted on.

Individualised care plans detailed the support and care each person required. People confirmed they received the support and care they needed and liked. The home ensured relevant health care professionals were contacted when needed.

People had a choice of menu at meal times and were provided with the necessary support to ensure they were able to eat and drink sufficient amounts to meet their needs.

People who lived at the home were protected from the risk of poor health because infection control practices were followed. They were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

Recruitment procedures at the home meant that people were cared for, or supported by, suitably qualified, skilled and experienced staff.

We saw that records that related to the running of the home and the care provided to people were accurately maintained and stored securely.