We inspected this service on 3 December 2018.

Harmony House is operated by Larchwood Care Homes (North) Limited; a large provider of care homes. Harmony House provides nursing care and accommodation for up to 57 people. The majority of people who live at the home are people living with physical frailty due to complex health conditions and / or older age. Some people are living with dementia. The home offers end of life care to people. The home provides one temporary ‘discharge to assess’ bed for a person who has come from hospital for further care or assessment before going back to their own home or finding a suitable care home. At the time of our visit there were 36 people living in the home.

People in care homes receive accommodation and 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.

There was a newly appointed manager in post. They had begun the process of applying to become registered with us for this service. 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 in September 2017 we rated the service as Requires Improvement. This was because in five of the key areas we checked, we found improvements were required. Following our September 2017 inspection, the regional manager has updated us weekly on their progress. At this inspection, we found some improvements had been made in the five key areas we checked. However, further improvements were still required. The overall rating continues to be Requires Improvement.

People were supported by trained staff, who overall, followed the provider’s policies and training given to them. People felt staff had the appropriate levels of skill, experience and support to meet their care and support needs. Individual risk management plans were in place for staff to follow and staff knew what action to take in the event of an emergency.

Staff understood their responsibilities to protect people from the risks of abuse and told us they would share any concerns they had following the provider’s safeguarding policies. The provider’s regional manager and home manager understood and followed their legal responsibilities when safeguarding concerns were identified to them by staff or through checks made. The provider checked staff’s suitability to deliver care and support during the recruitment process.

People were supported to eat a balanced diet and encouraged to eat and drink enough to maintain their wellbeing. Overall, staff supported people to access support from external healthcare professionals to maintain and promote their health.

People received their medicines as prescribed, but staff had not always followed the manufacturer’s guidance in relation to medicines given through skin patches. Overall, medicines were stored safely, though staff did not consistently ensure medicines were locked in the trolley when it was left unattended. Overall, people were protected from the risks of cross infection and the home was clean and tidy.

Staff had received training in the Mental Capacity Act 2005 and worked within the principles of the Act. Managers understood their responsibilities under the Act and when ‘best interests’ meetings should take place. Staff supported people with kindness and in a caring way to meet their physical care and support needs. People’s privacy and dignity was respected.

People had individual plans of care which provided staff with the information they needed. Staffing levels meant staff focused on people's physical care needs and did not always have time to meet people's emotional needs. There were very limited activities offered to peo

The inspection took place on 1 and 2 August 2017. The visit was unannounced on 1 August 2017 and the inspection team consisted of two inspectors, an inspection manager and an expert by experience. An expert by experience is a person who has personal experiences of using or caring for someone who uses this type of care service. We informed the manager and regional manager that one inspector and an inspection manager would return to complete the inspection on 2 August 2017. We were joined on our second inspection day by the lead nurse for care homes from Warwickshire North Clinical Commissioning Group.

Harmony House provides accommodation, nursing and personal care and support for up to 57 people living with physical frailty due to complex health conditions and / or older age. At the time of the inspection 35 people lived at the home. The home is split over two floors; each with a communal lounge and dining area.

The home is required to have a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run. Since our last inspection there had been some changes in the management of the home. A new home manager had started work there during April 2017 and was in the process of becoming registered with us.

After our inspection in June 2016 we served the provider and previous registered manager a ‘warning notice’ because regulations had not been met and the service was rated as ‘inadequate’. In January 2017 we inspected again. During this inspection visit we found improvements had been made and the home was rated as ‘requires improvement’. However, there continued to be a breach of the regulations in relation to the governance of the home, and a breach of the regulation in relation to the safe care and treatment of people. The provider agreed voluntarily to restrict admissions to the home until improvements were made and send us improvement action plans each month, which they did.

At this inspection, we found sufficient improvements had been made to meet the requirements of the warning notice and regulation relating to governance of the home. The rating remains ‘requires improvement’ with no breaches of the regulations.

The home manager and a new regional manager, who had also started during April 2017, told us they had implemented improvements and had further improvements planned for. The manager told us a change in culture at the home was work in progress and their passion was to create a home that offered a good service to people. The manager felt supported by the regional manager who visited and spent time at the home every week. Staff felt supported and were complimentary about the management changes.

There were however some provider led changes that staff felt impacted on them. The manager and regional manager had agreed to escalate some of these concerns to senior management.

Overall, people and their relatives felt improvements were being made. People knew who the manager was and relatives described them as approachable. Systems were in place to gain feedback from people and plans were in place to provide opportunities for people, relatives and staff to give feedback during August 2017.

Improvements had been made, overall, to the safe care and treatment of people. Most risks of potential harm to people were identified. However, where risks had been assessed, actions to minimise those risks were not always followed by staff. Staff felt they knew what to do in the event of emergencies. However, the provider’s fire risk assessment recommendation had not been incorporated into planned fire drills.

Safe systems were in place for recruiting staff. People had their prescribed medicines available to them and were supported wit

The inspection took place on 10 and 11 January 2017. The visit was unannounced on 10 January 2017 and we informed the registered manager we would return on 11 January 2017.

Harmony House provides accommodation, nursing and personal care and support for up to 57 people living with physical frailty due to older age and complex health conditions. At the time of the inspection 37 people lived at the home. The home has two floors; on the days of our visit, the ground floor offered two residential care beds and 15 nursing beds. People on the first floor all required nursing care.

The home is required to have a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run. At the time of this inspection the home had a registered manager who had been in post since March 2015 and registered with us since August 2015.

When we inspected the home in March 2015 we found a breach in the governance of the home and the legal requirements and regulations associated with the Health and Social Care Act 2008 were not being met. A requirement notice was served on the provider to tell us what action they would take to make improvements. At our last inspection in June 2016, we found improvements had not been made. We identified breaches in the management of medicines and the safe care and treatment of people. A continued breach in the governance of the home resulted in enforcement action being taken and we served a warning notice on the provider and the registered manager. The home was placed in ‘special measures.’ The special measures framework is designed to ensure a timely and coordinated response where we judge the standard of care to be inadequate. Services in special measures are inspected again within six months following the publication of the inspection report.

At this inspection we looked to see if the provider and registered manager had responded to make the required improvements in the standard of care to meet the regulations. Whilst we found that sufficient improvements had been made to remove the service from ‘special measures,’ we found further improvements were required. The requirements of the warning notice served had not been fully complied with. Further improvements in how the senior managers assured themselves that they were providing a safe service, that ensured people’s health and welfare needs were fully met, were required. The registered manager showed us the service development plan that provided details of further planned improvements.

Systems in place to assess the quality of the service provided were not always effective and improvements had not been fully implemented. Checks undertaken by nurses, the deputy manager and registered manager to ensure the safe management of medicines and people’s care and treatment was safe, had not identified potential areas of risk. Whilst some improvement had been made, further improvements were required.

Feedback was sought from people and their relatives but improvements were not always effectively made in the areas that mattered most to people. Staff did not always feel supported by management. Staff felt the ‘culture and feel’ of the home needed to improve so concerns could be openly raised with management and feedback given.

Nurses had been trained to use an electronic system when administering people’s medicines and felt supported with this. However, further improvements were needed so that nurses had the information they needed to ensure ‘when required’ medicines given consistently to people and in ensuring storage of medicines was undertaken safely.

Risk assessments to minimise where people may be at risk of harm or injury and the required actions, had not always bee

The inspection took place on 7 and 8 June 2016. The visit was unannounced on 7 June 2016 and we informed the provider we would return on 8 June 2016. We gave feedback about concerns we had identified to the registered manager and regional manager on 8 June 2016. An inspector and inspection manager returned, unannounced, on 14 June 2016 to check if immediate actions had been taken in response to concerns identified had been implemented by the registered manager to address issues we identified.

Harmony House provides accommodation, nursing and personal care and support for up to 57 older people living with physical frailty due to older age and complex health conditions. At the time of the inspection 52 people lived at the home. The home has two floors; on the days of our visit, the ground floor offered six residential care beds and 16 nursing care beds. People on the first floor all required nursing care.

The home is required to have a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run. At the time of this inspection the home had a new manager; who had been in post since March 2015 and registered with us in August 2015.

When we inspected the home in March 2015 we identified a breach in the regulation relating to good governance of the home. In addition to the new manager that had started, in January 2016, the provider of the home, Larchwood, had arranged for Healthcare Management Solutions (HCMS) to take over as managing provider of the home from the previous managing provider. At this inspection, we found insufficient improvement had been made by the registered manager and the managing provider to meet the regulation relating to good governance. However, the HCMS regional manager shared a developmental plan with us which showed they had identified some issues that required improvement. We found further areas that required improvement that had not been identified as part of the development plan.

People did not always have their prescribed medicines available to them because staff had not ensured adequate stocks were available. Risks to people had been assessed, however, actions staff should take were not always detailed which meant risks of harm and injury were not minimised. Staff understood their role in protecting people from abuse and what actions to take if they had concerns.

People felt there were not always enough staff available on shift to meet their needs when support was requested. Some people felt staff were positive towards them but this was not consistent and care was not personalised. People and relatives shared concerns with staff and the registered manager. However, whilst they felt listened to, concerns and complaints raised were not always effectively responded to or resolved to people’s satisfaction.

Staff worked within the principles of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. People told us that most staff were kind and had a caring approach but did not always have the time to effectively care for them. Staff did not consistently respect people’s dignity when supporting them. Most people enjoyed the varied group activities offered at the home, but a few people felt socially isolated in their bedrooms.

Risks to people’s nutritional health had been assessed but these were not effective because actions to minimise identified risks were not completed. For example, when weight loss was identified, these people were not offered extra calories in their meals or as snacks. Drinks were offered to people and support was given when needed, however people did not always have drinks left within their reach. Staff referred people to healthcare professionals when needed, b

We inspected Harmony House on 18 March 2015 as an unannounced inspection. At our previous inspection in June 2014 we found there were breaches in the legal requirements and regulations associated with the Health and Social Care Act 2008 related to Consent to care and treatment, Care and welfare of people who use services, Medicines, and Assessing and monitoring the quality of service provision. We asked the provider to send us an action plan to demonstrate how they would meet the legal requirements of the regulations, and the actions had been completed.

We found there was a breach in the legal requirements of Regulation 20 Records, of the Health and Social Care Act (Regulated Activities) Regulations 2008, which corresponds to Regulation 17 of the Regulations 2014. This was because care records did not consistently record how care was delivered to people, which put people at risk of receiving inconsistent care.

Harmony House is divided into two separate floors and provides personal and nursing care and accommodation for up to 57 older people, including people living with dementia. There were 45 people living at Harmony House when we inspected the service.

A requirement of the service’s registration is that they 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 and associated Regulations about how the service is run. There was a registered manager in post at the time of our inspection.

There were enough staff available to safeguard the health, safety and welfare of people. Staff were given induction and training so that they had the skills they needed to meet the needs of people at the home. However, staff were not supported with regular supervision meetings.

We found that people were protected against the risk of abuse, because the provider took appropriate steps to recruit suitable staff. The provider had appropriate policies and procedures in place to report abuse, or allegations of abuse.

The manager understood their responsibility to comply with the requirements of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. Where people could not make decisions for themselves people’s rights were protected; decisions were made in their ‘best interests’ in consultation with health professionals.

People were supported to have food and drink that met their health needs and met their preference.  People were supported to access healthcare professionals to maintain their health and wellbeing.

We saw care staff treated people in a caring manner, and respected people’s privacy and dignity. Staff encouraged people to maintain their independence.

People made choices about who visited them at the home. This helped people maintain personal relationships with people in the community.

People knew how to make a complaint if they needed to. Complaints were fully investigated and analysed so that the provider could learn from them. Action was taken to improve the service following complaints.

People who used the service, and their relatives, were given the opportunity to share their views on the quality of the service. Quality assurance procedures were in place to identify where the service needed to make improvements, and where issues had been identified the manager took action to improve the service.

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

Two inspectors carried out this inspection on Wednesday 25 June 2014. One visited the service from 9.30am to 7pm and the other visited from 11.30am to 4.30pm. We spoke with the new manager, a regional manager, three visiting relatives, a visiting social care professional, three people who used the service, three nursing and two care staff. The evidence we collected helped us to answer five key questions; is the service safe, effective, caring, responsive and well led?

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

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

Is the service safe?

The provider understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). There was one person living at Harmony House who had a current DoLS in place and two were being applied for.

The service had recruited new staff. We saw their recruitment practice reduced the risks of employing potentially unsuitable staff. It also ensured staff had the skills, knowledge and experience to work with people.

We were aware there had been concerns about the administration of medicines. We saw the service had made improvements but there continued to be some issues around medication management.

Is the service effective?

We had been made aware by Warwickshire County Council and Arden Clinical Support Unit (CSU) that since our last inspection the service had problems with staffing, medication and infection control. Action plans had been put in place to address issues and the service was improving.

People all had an individual care plan which set out their care needs. These provided staff with the information they needed to support people with their care. Assessments included people’s needs for equipment, skin integrity and specialist dietary requirements. We saw some inconsistencies and insufficient information in some care records which could impact on the care provided.

People were not fully involved in their care planning and reviews. The new manager was aware of this and had organised staff seminars to start this process.

Is the service caring?

We observed most staff were caring and kind to people living at Harmony House. Some care staff were task focused and we did not see much engagement with people unless they were carrying out a care task.

People living at Harmony House told us staff were caring. They said, “Staff are always helpful.” “I think it’s very good (the care).” “On the whole, pretty good...they do their best…they’re understaffed sometimes.”

Is the service responsive?

An activities worker provided people who lived on the ground floor with a good range of activities to stimulate and entertain. The service was less responsive to the social and emotional needs of people being provided with nursing care on the first floor. We saw little engagement with staff apart from when care tasks were being carried out.

We saw people were referred to appropriate health and social care professionals such as the GP, dietician, and tissue viability nurse. On the day of our visit we saw a social worker was visiting a person living in the home.

Is the service well-led?

Since our last inspection the service had been through management changes and had no manager in place for a while. The organisation supported the deputy manager to act up as manager until a new manager was recruited.

The new manager had been in post since 2 June 2014. They were aware of the issues which needed addressing and were beginning to take action to address them. The manager had not been in post long enough to carry out all the necessary changes.

Information from the analysis of accidents and incidents had been used to identify changes and improvements to minimise the risk of them happening again.

When we visited Harmony House we spoke with four people who use the service about their experiences of living in the home. We also met and spoke with one nurse, three care staff, nine relatives, the acting manager, the activities co-ordinator and the cook. We also had general discussions with other staff that were on duty.

The acting manager had recently been confirmed in post. People told us that they felt that he was making noticeable improvements in the home. “X is very good - he is making a difference."

People and relatives we spoke with told us that they enjoyed living in the home, and that the staff were caring. "It's very good actually, I can't fault them", "The staff are lovely, they treat X like he is their Dad", "The staff are very, very good" and "Some staff are better than others but generally the care is good" were comments made to us.

People's care needs were assessed and care records were up to date and provided clear information of how staff were to provide care and support for people.

We saw that people appeared relaxed in the company of the staff.

People were provided with good food with plenty of choice. Special diets were provided for. Where people were at risk of malnutrition or dehydration, measures were in place to ensure that people received sufficient food and drinks.

A complaints procedure was available. Relatives told us that they felt that the acting manager was listening to their concerns and they were now being addressed.

The safe handling of medicines was assessed by a pharmacist inspector. Our inspection in March 2012 found that people were not fully protected against the unsafe use of medicines. A compliance action was made in relation to this.

At this inspection we looked at people’s Medication Administration Record (MAR) charts, the storage of medicines and spoke with three members of staff. We found that the arrangements for storage, recording and handling of medicines had improved.

During our last review of this service in 2011 we identified concerns and issued three compliance actions. These related to the care of people, medicine management and completion of records. In October 2011 the home was purchased by a new provider. We therefore carried out this visit to assess compliance in these areas and to see if there had been any improvements in standards as a result of a new provider taking over. During this visit we found evidence of non compliance within these three areas.

Most of the visitors and people that we spoke with were positive in their comments about the home. Comments included: “I am looked after well enough in here. Everybody is good to me.” “It’s as good as anywhere we are going to get, I can go away from here knowing X is well looked after.”

We found that that some people had not received their medicines as prescribed to help maintain their health.

We found that there were a number of new staff working in the home who were still familiarising themselves with people’s needs and preferences. Care records that we saw were not always helpful in supporting staff to identify people’s needs to ensure they were met.

We visited this service on 10 and 13 August 2012. The visit was unannounced so that no one who worked for or used the service knew we were coming.

We carried out this inspection to check on the care and welfare of people using this service. We also checked that the concerns we had raised during our last visit to the home on 21 March 2012 had been addressed.

We did not look at the concerns relating to the management of medicines, identified at the last visit, at this inspection. The management of medication in the home will be fully assessed by a pharmacist inspector at a later date. There has been a visit to the home by the Primary Care Trust Pharmacist prior to our visit. We have received a copy of the findings and planned actions the home intends to take to address the issues identified.

During our visit we spoke with three people using the service, three relatives, the care staff on duty, the manager, a support manager and a project manager.

People we spoke with told us that they liked the home and were happy with the care, treatment and support either they or their relatives were receiving. Comments made included "I like it here, it's very nice" and "The care is very good, he gets everything he needs."

We observed positive relationships between people living in the home and the staff on

duty. We saw that people appeared comfortable and relaxed.

People had care plans in place that contained current information, and assessments to assist staff with meeting their care, treatment and support needs.

Staff we spoke with knew about people's care, treatment and support needs and were able to tell us about them. We saw that personal care and support was provided in private.

Staff we spoke with were knowledgeable about safeguarding vulnerable adults from abuse and were able to talk through the processes to be followed should abuse be suspected. Staff confirmed that there was a whistleblowing policy in place and told us that they would feel confident using it if they felt it was necessary.

We saw that people's records were stored safely, were in good order, upto date and current.

Where we have identified areas that could be improved upon we have made reference to these in the report.