Archived: Harewood House

Harewood House is registered to provide accommodation for up to 29 older people, almost all of whom are living with dementia or a dementia related condition. Many of the people at the service have specialist needs relating to their behaviour and wellbeing. Accommodation is provided over three floors. There were 17 people living at the service when we inspected.

There was a registered manager in post who had registered with CQC in November 2016. 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 the last comprehensive inspection on 25 August 2016, we identified breaches of regulations. The registered provider had failed to provide appropriate supervision to staff, manage risks to people, implement adequate care documentation and monitor and govern the service. The service was rated at that time as inadequate overall and placed into special measures. The registered provider wrote to us telling us what action they would be taking in relation to the breaches of regulation. The registered provider agreed to a voluntary suspension on new admissions. This voluntary suspension was still in place at the time of this inspection.

The service was placed into the collective care process with the local authority in September 2016 due to the number of concerns which had been raised by visiting professionals and CQC. At the time of this inspection Harewood House was still in the collective care process and meetings were ongoing, which CQC had attended.

At this inspection we found the registered provider and registered manager had begun to implement their action plan but we found many concerns still outstanding. We found continued breaches of three regulations relating to safe care and treatment, good governance and staffing.

Risk assessments contained limited information and did not always match care plans. The risk assessments were not regularly reviewed. Some people did not have risk assessments in place when they needed them.

A fire risk assessment had been completed but appropriate action had not been taken to address concerns raised by the fire authority. There were no personal evacuation plans in place. Smoke alarms were not in place where required and regular fire drills had not taken place. The testing of fire alarms had not been recorded appropriately. There were a number of fire doors that did not close correctly and no action had been taken to correct this. Hot water temperatures were not checked to reduce the risk of scalding.

Throughout the inspection we identified several items such as old beds and moving and handling equipment stored in bathrooms and unoccupied bedrooms. Doors had not been secured and these rooms were accessible to all people. Items of furniture and moving and handling equipment were also stored in communal areas. We found broken and damaged furniture in people's bedrooms which could not be cleaned properly.

Accidents and incidents had not been adequately recorded. There were no clear audit trails and the registered manager did not review accidents and incidents. We could not be sure if appropriate action had been taken when an accident or incident had occurred.

Staff we spoke with understood the procedure they needed to follow if they suspected abuse might be taking place. The provider had a policy in place to minimise the risk of abuse occurring. Safeguarding alerts had been submitted to the local authority when needed and appropriate action had been taken.

Medicines were managed appropriately. The provider had policies and procedures in place to ensure that medicines were handled safely. However, this did not contain information on medication that was prescribed ‘as and when required’ or homely remedies. Medication administration records were completed fully to show when medicines had been administered and disposed of.

There was sufficient staff on duty to support people and rotas that we looked at corresponded with staffing levels on the day of inspection. Safe recruitment processes had been followed.

The induction process for new staff was not sufficient to enable them to be fully prepared for their new role. Staff had received training to enable them to support people safely but no practical training had been provided. For example, staff had been shown how to use equipment, such as hoists, by the registered manager who was not an accredited trainer. Staff had begun to receive one to one supervisions to support them within their roles but appraisals had not taken place.

Some best interest decisions lacked professional involvement and it was not clear from the information that was recorded who had been involved in the decision making. The principles of the Mental Capacity Act 2005 were not always followed by staff. People who were subject to a Deprivation of Liberty Safeguard had all relevant documentation available in there care files and DoLS renewal applications had been submitted in a timely manner.

People were encouraged to eat a varied and balanced diet. The meals that were served on the day of inspection matched what was on the menu. Observations showed that people enjoyed the food on offer at the service. Food and fluid monitoring forms had not always been completed fully and contained several gaps in recordings. Records showed that requests for other professional's involvement, such as dieticians, had been recorded appropriately.

Some staff demonstrated caring support but did not always speak to people appropriately to achieve positive outcomes. Relatives told us staff treated people with dignity and respect. Relatives told us they felt they had an input into their relative's care but this was not recorded.

People did not always receive care that was responsive to their needs. We found that some care plans were person centred although this was inconsistent. Others did not always contain details of what was happening in practice. There were no planned activities on offer at the service and we saw very little interaction between people and staff.

The registered provider had a complaints policy that was displayed at the service. This did not contain all the relevant information and required updated information. Relatives told us they were aware of their right to make a complaint.

The service was not well-led. The registered manager did not receive sufficient support from the registered provider. Many quality assurance systems were not in place and the registered manager did not effectively monitor the safety and quality of the service.

The overall rating for this service remains ‘Inadequate’ and the service remains 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 could lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

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.

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

Harewood House is registered to provide accommodation for up to 29 older people, almost all of whom are living with a dementia or a dementia related condition. Many of the people at the home live with an advanced dementia and have specialist needs relating to their behaviour and wellbeing. Accommodation is provided over two floors and there were 22 people living at the service when we inspected.

The home did not have 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 the last comprehensive inspection of this service on 21 April 2015 shortfalls were identified in relation to infection control. At this inspection, the registered provider had made improvements to infection control practice and the service was no longer in breach of this regulation.

The provider had not ensured staff followed their missing person’s policy and procedure and had therefore not ensured that people were protected. Risk assessments did not provide sufficient guidance for staff to offer care which protected people from harm while maximising their freedom.

People were not adequately protected from abuse and avoidable harm.

Staff were not receiving adequate supervision and appraisal to support them to offer effective care.

The service was not responsive to the needs of all the people who used the service.

Care planning did not sufficiently address people’s detailed needs in relation to all areas of their care and wellbeing.

The manager had not received an adequate induction process to their role and had been left to manage the service without sufficient induction or support. This had led to a number of concerns including the placing and appropriateness of admissions to the home.

The registered provider had not informed CQC about safeguarding incidents or other events which they are required to do by law. We found they did not have effective auditing procedures in place to ensure they had the information needed to monitor and plan improvements.

Effective and safe systems and processes to ensure compliance with legal requirements and to keep people safe were not in place and governance of the service was inadequate.

Medicines were safely handled to protect people.

Staff were able to tell us what they would do to ensure people were safe within the home. The home had sufficient suitable staff to care for people and staff were safely recruited. The environment of the home was safe for people.

Staff had received training to ensure that people received care appropriate for their needs. Training was up to date across a range of relevant areas and the manager planned to improve this further with a range of face to face training to supplement the e-learning already offered.

Staff had received up to date training in Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). They understood that people should be consulted about their care and understood the principles of the MCA and DoLS. People were not fully protected around their mental capacity because mental capacity assessments were sometimes not sufficiently detailed to give staff appropriate guidance.

People’s nutrition and hydration needs were met. They enjoyed the meals which were of a good quality. Specialist advice around people’s health care was sought and followed.

Some people had not received a caring service when they had left the building without staff noticing, or when a person was inappropriately admitted to the home. However, most people were treated with kindness and compassion. We saw staff had a good rapport with people whilst treating them with dignity and respect. Staff had knowledge and understanding of people’s needs and worked together well as a team.

Records and observations provided evidence that people were treated in a way which encouraged them to feel valued and cared about.

People were supported to engage in daily activities they enjoyed and which were in line with their preferences and interests. However, they did not often have the opportunity for outings.

People told us their complaints were responded to; however there were no records of complaint investigations as the acting manager told us that there had been no formal complaints. Visitors told us that if they had concerns they were always addressed by the manager who responded quickly and with courtesy.

The manager had recently taken on their role. Visitors and health and social care professionals told us the manager was approachable and supportive of staff. The manager responded positively to the inspection process and was open to improving their practice. They told us of a number of plans they had for improving the service around care plans, risk assessments, care reviews, the quality and scope of audits, infection control, and updating policies and procedures. They were also planning to consult more effectively with people, their representatives, and professionals who were involved in people’s care.

We identified multiple breaches of regulation relating to person centred care, safe care and treatment, governance of the service and staffing. We also identified offences in relation to failure to notify and the provider’s statement of purpose which we will follow up separately. You can see the action we have taken at the back of this report and we will be pursuing all of these matters directly with the registered provider.

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.

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

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

This is a summary of what we found.

Is the service safe?

People were treated with dignity and respect by the staff. Safeguarding procedures were robust and staff understood how to safeguard the people they supported. Systems were in place to ensure that the registered manager and staff learnt from incidents such as accidents and incidents. This reduced the risks to people and helped the service to continually improve.

The home had policies and procedures in relation to the Mental Capacity Act (MCA), 2005 and Deprivation of Liberty Safeguards, (DoLS). All staff had been trained to understand when an application should be made, and how to submit one. Documentation was available in people's care files to support this.

Staff had received up-to-date training in all mandatory areas, as well as those specific to their job role. Staff recruitment procedures were thorough and in accordance with the provider's policy. Staffing levels were determined based on the individual needs of each person living in the care home. Policies and procedures were in place to make sure unsafe practices were identified and people were protected.

The home had policies in place for the effective control of infection and the environment was clean and tidy.

Is the service effective?

Staff had the skills and knowledge to meet people's needs. The registered manager gave effective support to staff including induction training, supervision and appraisal. This was supported by a comprehensive training programme. The care home worked effectively with other agencies and health care services to ensure a co-ordinated approach to people's care was achieved.

Is the service caring?

People living in the care home were supported by kind and attentive staff. They were cared for sensitively and given encouragement. People's preferences, interests and diverse needs had been recorded and care and support had been provided in accordance with people's wishes.

Is the service responsive?

The complaints procedure was understood by staff, people living in the care home and their relatives. The registered manager had encouraged relatives to have greater involvement in the care offered.

Is the service well led?

There was a quality assurance process in place. Records showed that any adjustments needed were actioned promptly. This enabled the quality of the service to continually improve. Staff told us they were clear about their role and responsibilities. The staff we spoke to felt they were strongly supported by the registered manager. Staff had received ongoing training in order that they may continue to provide effective care. The registered manager monitored the needs of the people and adjusted staffing levels accordingly. This meant that people were safe and their health and welfare needs were met by sufficient numbers of appropriate staff.

We looked at the way in which nutrition was managed in the service.People were able to have what they liked to eat at every meal. There was a set menu at lunch time but there was flexibility and the manager told us that if people did not like what was on the menu there was an alternative available

We looked at communal areas, the kitchen, all the bedrooms and bathrooms during the visit. These were all clean and free from clutter and odours. Each person had their own bedroom .The bedrooms were of a size and shape that supported the lifestyle of people who used the service. People who used the service were able to choose what furniture they had in their rooms. Some people had brought their own furniture. One person told us,"I have a lovely room".

Appropriate checks were undertaken before staff began working at this service including criminal record checks.

People who used the service told us, "I like living her, they are very good". We observed the service and found it to be clean, tidy and free from unpleasant odours