Hartwood House is a care home with nursing. People in care homes receive accommodation and their care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided and both were looked at during this inspection. Hartwood House provides accommodation for up to 50 people. It is arranged over three floors. The Emery Down Unit is on the lower ground floor and provides care for up to 10 people. The Limewood unit on the ground floor provides care for 20 people and the Minstead unit is on the first floor and currently focuses on caring for up to 20 people living with dementia.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 last inspection, the service was rated overall as ‘Good’. At this inspection we found the service remained overall ‘Good’ but with some areas where improvements could be made, for example, improvements were needed to how some aspects of people’s medicines were managed and we found that in a small number of cases, risks to people’s health and wellbeing were not being effectively managed. Staff raised concerns about how, and the number of, staff were deployed. They felt that at times, this prevented them from meeting people’s needs in a timely manner.

Other areas were good or outstanding.

Staff had an excellent knowledge and understanding of the people they were supporting and this helped to ensure people received care and support which was responsive to their needs. Staff went the extra mile to provide care that was meaningful to people and provided them with opportunities to access their community and take part in events that were of interest to them.

Communication was provided in ways which met people’s individual needs, including the use of information technology, so they had access to information that was meaningful to them

Appropriate checks had been made to ensure that new staff were suitable to work in the home.

Accidents and incidents were investigated and action taken to reduce the risk of further harm.

Care plans provided a record of people’s individual needs and staff were provided with opportunities to develop their skills and knowledge and performed their role effectively.

Staff sought people’s consent before providing care and people were encouraged and supported to make decisions about their care and support. Staff worked in accordance with the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards were applied appropriately.

People were supported to have enough to eat and drink and the premises were purpose built and their design and layout met the needs of people using the service.

Where necessary a range of healthcare professionals including GP’s, dentists and speech and language therapists, had been involved in planning peoples support to ensure their health care needs were met.

People were cared for by kind and compassionate staff. Staff were passionate about their role and spoke with enthusiasm about providing person centred care. People were treated with dignity and respect.

Feedback showed that staff provided compassionate care to people reaching the end of their life. Plans were in place to develop more detailed end of life care plans to support this.

The registered manager and provider had systems in place to monitor the quality and safety of care people received. The provider sought feedback from people, their relatives and from staff and used this to continually improve the service.

People and their relatives spoke positively about the registered manager. They felt the home was well run and they all said they would recommend the home to others. So

This inspection took place on 15 and 16 February 2016.

Hartwood House is a care home with nursing. It is arranged over three floors and consists of a new purpose built wing attached to an older existing property which has also been completely refurbished. The home can accommodate up to 50 people but at the time of our inspection there were 36 people living at the home. The Emery Down nursing unit is on the lower ground floor and provides care for up to 10 people who have nursing needs. The Limewood unit on the ground floor provides care for up to 20 people who require residential care. The people living on this floor are more independent and may need support with some daily living tasks such as personal care or support with their medicines management. The Minstead unit is on the first floor and can provide care for up to 20 people who are living with dementia. A registered nurse is based on the Emery Down Unit and is available to provide some emergency clinical advice or support to the other two floors which are staffed by senior care workers and care workers.

The home had 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 reliance upon staff working extra shifts and on bank and agency staff to maintain safe staffing levels. This meant that people did not always receive care from a stable and consistent staff team.

Some aspects of how medicines were managed within the service required improvement. Staff had not always followed guidance in relation to how the administration of PRN or as required medicines was recorded. Accurate records had not always been maintained about the medicines people were prescribed. We have made a recommendation about this.

Appropriate recruitment checks took place before staff started working at the home although we did note that in two of the records viewed, staff had not provided a full employment history. This information was provided following the inspection.

People’s records contained appropriate risk assessments which covered a range of areas. Care workers said that the risk assessments told them what they needed to know about each person and how to deliver their care safely.

The provider had a business continuity plan which set out the arrangements for dealing with foreseeable emergencies such as fire or damage to the home and the steps that would be taken to mitigate the risks to people who use the service.

People told us they felt safe living at Hartwood House. Staff had a good understanding of the signs of abuse and neglect and they were aware of what to do if they suspected abuse was taking place.

Staff acted in accordance with the principles of the Mental Capacity Act 2005. CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Where people’s liberty or freedoms were at risk of being restricted, the proper authorisations were in place or had been applied for.

Care plans contained information about people’s dietary needs and risks associated with these. People told us they enjoyed the food provided.

The home worked effectively with a number of health care professionals to ensure that people received co-ordinated care, treatment and support including memory nurses supporting those living with dementia and physiotherapists and community dentists.

People were treated with dignity and respect and staff were kind and caring in their interactions with people and people and their relatives were involved in making decisions and planning care.

People and their relatives told us that the permanent staff had a good understanding of their needs and of their preferences in terms of how their care was provided. Rec

We carried out an unannounced comprehensive inspection of this service on 2 and 6 January 2015. Breaches of the legal requirements were found. This was because the provider had not maintained an accurate record of the care and treatment provided to people. The provider had not taken sufficient steps to ensure that there were enough suitably qualified staff deployed at all times to meet people’s needs and the provider did not have suitable arrangements in place to ensure it was meeting the requirements of the Mental Capacity Act 2005. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches.

We undertook this focused inspection to check that they had followed their plan and to confirm whether they now met the legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for (location's name) on our website at www.cqc.org.uk

Hartwood House is arranged over three floors and consists of a new purpose built wing attached to an older existing property which has also been completely refurbished. The home can accommodate up to 50 people but at the time of our inspection there were 39 people living at the home.

The Emery Down nursing unit is on the lower ground floor and provides care for up to 10 people many of whom have complex nursing needs. A registered nurse is based on this unit and is available to provide some emergency clinical advice or support to the other two floors which are staffed by senior care workers and care workers.

The Limewood unit on the ground floor provides care for up to 20 people who require residential care. The people living on this floor are more independent and may need support with some daily living tasks such as personal care or support with their medicines management.

The Minstead unit is on the first floor and can provide care for up to 20 people who are living with dementia. Some of the people living on this floor could at times act in a manner which others could find challenging and which could place them or others at risk.

Following a review of records relating to people’s care, we found that we had not been notified of two potential safeguarding incidents which had occurred within the service. The local authority had also not been informed. Whilst appropriate actions appear to have been taken, registered persons are required to notify the CQC without delay of such incidents. This had not happened.

The home had 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.

People told us they felt safe living at Hartwood House and were cared for by kind, caring and compassionate staff. This was echoed by their relatives. Comments included, “He has special moments with staff”, “They are caring with a capital C” and “Hartwood House is a little treasure”.

Improvements had been made to the staffing levels within the service; however some people and staff felt that these could improve still further. Agency staff were required on a regular basis and recruitment and retention of staff remained a challenge, but we saw that the provider was taking action to address this.

The registered manager did not use a formal approach to assist in reaching judgements about staffing numbers and we have made a recommendation about this.

Overall we found that people’s care plans were more detailed and were being reviewed regularly with the person, their relatives and where relevant with external professionals. It was evident that staff were working hard to personalise and improve the level of detail contained within people’s care plans. Most people’s care and monitoring records were being more consistently maintained and more accurately reflected the care and support they received.

We did find that some aspects of people’s care records could be improved still further, for example, where people were living with dementia, they did not have a dementia care plan. Dementia care plans are important as they provide staff with Individually tailored guidance that supports them to promote and maintain the person’s independence and adapt and develop their skills. We have made a recommendation about this.

Mental capacity assessments had been undertaken which were decision specific. Where people were deemed to lack capacity, appropriate consultation had been undertaken with relevant people such as GP’s and relatives to ensure that decisions were being made in the person’s best interests.

Improvements had been made to ensure that staff had training relevant to their role. Staff were receiving more regular supervision and had received an appraisal of their performance.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have taken at the back of the full version of this report.

Hartwood House opened in May 2013. The home can accommodate up to 50 persons in total across a residential unit, a dementia care unit and a nursing unit. On the day of our inspection there were 32 people living at the home.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well-led?

This is a summary of what we found. The summary is based on our observation during the inspection, speaking with eleven people using the service, five relatives and from looking at nine people’s care records. We also spoke with the registered manager, eight care workers and one nurse.

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

Is the service safe?

People’s care records contained assessments which covered the risks associated with staff providing the care and support they needed. This helped to ensure that people who use the service were safe because staff had taken action to identify and assess the risks to their health and welfare.

People told us that they felt safe. Safeguarding procedures were in place and staff understood how to safeguard the people they supported.

Systems were in place to ensure that the service learnt from incidents and accidents, comments and complaints.

Overall the home was adequately staffed, however, the service was reviewing its staffing arrangements to ensure that there continued to be sufficient numbers of qualified, skilled and experienced staff to meet all people’s needs.

The premises were decorated and maintained to a high standard to ensure the safety and comfort of people who use the service.

Is the service effective

People’s needs had been assessed and care and support was planned and delivered in line with their individual care plan. Care plans were detailed and regularly reviewed.

Staff we spoke with were informed about people’s needs and were able to tell us about the care they provided. This information was consistent with what was recorded in people’s records.

The service worked effectively with other providers to ensure that people received co-ordinated care, treatment and support.

Is the service caring?

People were supported by kind and attentive staff. Staff treated people with dignity and respect and we saw that care was delivered in an unhurried and sensitive manner. One person told us, “It’s very nice here…the staff are very kind”. A relative told us, “The staff are very good and we are happy. They look after [their relative] as a whole person and meet their needs well”.

People’s preferences, likes and dislikes had been recorded and care and support was provided in accordance with peoples wishes.

Is the service responsive?

The service had measures in place to review people’s needs on a regular basis. Where concerns were identified, we saw that action had been taken to address these.

People knew how to complain and told us that they were confident that action would be taken where necessary.

There were arrangements in place that ensured people who use the service, their representatives and staff were asked for their views about their care and treatment the service provided. Where the need for improvement was identified action was taken to do this.

Is the service well led?

The service had a consistent management structure that maintained oversight of the home and provided leadership to the staff team.

Staff told us that they felt the service was ‘well led’ and that the manager was ‘a strong leader’. One care worker told us, “If I had a problem I could go to them [the manager] they are really organised and have a presence on the floor, they have tea with the residents, they are very hands on”. Another care worker told us, “I have had so much help from the manager, they are very understanding and supportive….this home is one of the best I have ever worked in, it’s fantastic”.

The service had a robust quality assurance system in place to monitor the quality of the service and identify where improvements could be made.

This inspection took place on 2 and 6 January 2015 and was unannounced.

Hartwood House opened in June 2013. The home is arranged over three floors and consists of a new purpose built wing attached to an older existing property which has also been completely refurbished. The home can accommodate up to 50 people but at the time of our inspection there were 33 people living at the home. The Emery Down nursing unit is on the lower ground floor and provides care for up to 10 people many of whom have complex nursing needs. The Limewood unit on the ground floor provides care for up to 20 people who require residential care. The people living on this floor are more independent and may need support with some daily living tasks such as personal care or support with their medicines management. The Minstead unit is on the first floor and can provide care for up to 20 people who are living with dementia. Some of the people living on this floor could at times display behaviour which challenged and also had some complex physical health needs. A registered nurse is based on the Emery Down Unit and is available to provide some emergency clinical advice or support to the other two floors which are staffed by senior care workers and care workers.

The home had not had a registered manager since June 2014. 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. A new manager was appointed in July 2014. They have made an application to be appointed the registered manager.

Staffing levels required improvement. People told us that they had to wait for support and assistance. Target staffing levels were not always met and staff struggled to meet people’s needs in a timely manner.

Mental capacity assessments were not being undertaken with due regard to the MCA 2005. When a person lacked capacity to make decisions about their care, we were not always able to see that appropriate best interests consultations had been undertaken.

People’s records did not always contain enough information about their needs to ensure that staff were able to deliver responsive care.

Some risk assessments needed to be updated to include more detailed and specific guidance to support staff to manage risks in a safe and effective manner.

Staff had not completed all of the training relevant to their role. Staff had also not received supervision in line with the frequency determined by the provider.

People’s nutritional needs were met, but improvements were required to ensure people had choice of suitable foods which encouraged their enjoyment of mealtimes and which were in keeping with their known preferences or their dietary requirements.

People said they had no concerns about the leadership of the home. However some staff told us they were not happy about aspects of their role and that morale amongst the staff team was low. The manager was aware that further work was needed to improve staff morale and to develop their confidence in her as their leader.

People told us they felt safe living at Hartwood House. Staff had received training in safeguarding vulnerable adults and had a good understanding of the signs of abuse and neglect. They were aware of what to do if they suspected abuse was taking place. The organisation had appropriate policies and procedures. This ensured that staff had clear guidance about what they must do if they suspected a person was being abused.

People were protected against the risks associated with medicines. The provider had appropriate arrangements in place to manage people's medicines safely.

Whilst a number of quality assurance systems were in place, this were not yet being fully effective and driving improvements.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Where people’s liberty or freedoms were at risk of being restricted, the proper authorisations were in place.

The home worked effectively with a number of health care professionals to ensure that people received co-ordinated care, treatment and support including memory nurses supporting those living with dementia and physiotherapists and community dentists.

People spoke positively about the care provided by the staff as did their relatives. One person described the staff as “Caring, kind and respectful….I never get one who is unkind”. A relative said, “I can’t fault them, they are so kind and caring, brilliant”.

People knew how to make a complaint and information about the complaints procedure was displayed within the home and included in the service user guide.

Systems were in place to see feedback from people who used the service, their relatives and staff. This helped to ensure the manager maintained an oversight of day to day issues within the home.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 which now corresponds to 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 the report.