About the service: Hartwell Lodge Residential 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 across two adapted buildings. At the time of the inspection there were 29 people living in the home. The service had stopped provided nursing care since the last inspection and were supporting some people who lived with a learning disability or dementia.

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.

This inspection took place on 11 and 12 December 2017 and was unannounced.

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 t

This inspection took place on 4 and 5 September 2017 and was unannounced. Prior to the inspection the Commission had received information of concern regarding staffing levels, moving and handling practices and treating people with dignity and respect. We looked at these concerns throughout our inspection.

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 th

This inspection took place on 22 and 23 March 2017. The inspection was unannounced and was prompted in part by notification of an incident following which a person using the service died. This incident is subject to a police investigation and as a result this inspection did not examine the circumstances of the incident.

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 recomm

This inspection took place on 4 and 5 October 2016 and was unannounced.

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 se

This comprehensive inspection took place on 10 and 11 February 2016 and was unannounced.

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 alway

A single inspector carried out this inspection. The focus of the inspection was 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 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.

People who lived at Merry Hall Nursing and Residential Home told us that they were happy living there. Processes were followed to ensure people were asked for their agreement before care and support was provided. Where people did not have the capacity to consent, the provider acted in accordance with legal requirements.

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.

People told us they were happy living at the home. They told us that “the staff are caring”. A visitor to the home told us that their friend “liked it here”. People were able to express their views and believed staff would try to respond to their views and wishes. People commented that the home arranges for them to see health care professionals such as General Practitioners (GP's) when they needed to.

People told us that they were able to make choices about their daily activities and routines; “I make my own decisions”. We were told about how they were able to choose whether to join in with group activities occupy themselves doing activities such a listening to music, watching television, reading books or knitting.

People told us there was always staff available to provide support and respond to call bells promptly. They told us they had confidence that staff had the necessary skills to provide the care and support they needed.

For some people living at the home, because of their level of dementia they were unable to directly communicate their needs and views. Because of this we used the Short Observational Framework for Inspection (SOFI) in one of the lounge areas. SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us. Our SOFI observation showed that staff were aware about how different people expressed their decisions. This meant that people who were unable to communicate directly were still able to express their choices and staff would respond to their choices.

People using the service told us they were happy living at the home. Staff listened to them

and respected their views and wishes enabling them to make choices about their daily

lives.

People confirmed they received care and support they needed in a way they liked. This

was because staff discussed the care and support they needed and wished for.

We were told they were able to discuss any concerns or complaints with staff members and

necessary actions would be taken.

People spoke about the pleasant environment at the home, including improvements made

following the decoration of several areas of the home.

People using the service told us they were happy living at the home. They felt safe because staff knew how to care and support them. Staff listened to them and respected their views and wishes and enabled them to make choices about their daily lives.

People told us that staff know how to look after them because they discuss what support and care they require. They knew that records were kept about them, but were not involved in updating their own records.

People were happy with the environment of the home and told us they were able to personalise their bedrooms with their own belongings.

We were told that if they had any complaints they would talk to staff and the necessary actions would be taken. Relatives of people using the service said they believed that concerns and complaints would be resolved promptly.