About the service:

Hawkinge House is registered as a community healthcare service, domiciliary care service, extra-care housing service, supported living service and a care home. A community healthcare service provides nursing and other clinical resources to people who live in their own homes. A domiciliary care agency provides personal care to people living in their own homes. A supported living service provides care and support to people living in supported living settings so that they can live as independently as possible. Under this arrangement people's care and housing are provided under separate contractual agreements. An extra care housing service provides care and support to people living in 'extra care' housing. Extra care housing is purpose built or adapted single household accommodation in a shared site or building. The accommodation is bought or rented and is the occupant's own home. In both supported living services and extra care housing services people's care and housing is provided under separate contractual agreements.

• Hawkinge House is registered to provide accommodation, nursing and personal care for 115 people. It can accommodate younger adults, older people and people who live with dementia. It can also provide care for people who need support to maintain their mental health and/or who have physical adaptive needs.

• There were 76 people living in the service at the time of our inspection. Sixty-six people who were living in the service at the time of our inspection had rented their accommodation in Hawkinge House. All these people received their nursing and personal care from members of staff employed by Hawkinge House Limited who was the registered provider.

Ten people received both their accommodation and care as part of a single package that was also delivered by the registered provider. Each person who lived in the service had their own bedroom with a private bathroom.

Rating at last inspection: ‘Inadequate’ (report published December 2018).

Why we inspected: At the last inspection on 10 September 2018 and 11 September 2018 the overall rating of the service was, ‘Inadequate’ and was placed into ‘special measures’. There were eight breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. There were serious shortfalls in the arrangements that had been made to provide people with safe care and treatment. These oversights included the arrangements made to prevent avoidable accidents.

Suitable systems and processes were not in place to supervise the operation of the service so that people consistently received the high-quality care they needed and had the right to expect. Robust arrangements had not been made to reliably safeguard people from situations in which they may be at risk of experiencing abuse.

Sufficient care staff had not always been deployed to enable people to promptly receive all the care they needed. Suitable background checks had not always been completed before new members of staff were appointed.

People had not always received care that promoted their dignity when they became anxious. People had not always received person centred care. This was because they had not always been given information in an accessible way to enable them to be fully involved in reviewing decisions made about their care. In addition to this, they had not always been fully supported to pursue their hobbies and interests.

Complaints had not been managed in a robust way that provided people with reassurance and enabled the service to learn from mistakes that had been made.

We found one breach of the Care Quality Commission Registration Regulations 2009. This was because the registered provider had failed to submit a statutory notification in line with our guidance.

• We told the registered provider to send us each month an action plan stating what improvements they had made and intended to make to address our concerns. The registered provider complied with this r

We inspected the service on 10 September 2018 and 11 September 2018. The inspection was unannounced.

Hawkinge House is registered as a community healthcare service, domiciliary care agency, an extra-care housing service, a supported living service and a care home. A community healthcare service provides nursing and other clinical resources to people who live in their own homes. A domiciliary care agency provides personal care to people living in their own homes. A supported living service provides care and support to people living in supported living settings so that they can live as independently as possible. Under this arrangement people's care and housing are provided under separate contractual agreements. An extra care housing service provides care and support to people living in 'extra care' housing. Extra care housing is purpose built or adapted single household accommodation in a shared site or building. The accommodation is bought or rented and is the occupant's own home. In both supported living services and extra care housing services people's care and housing is provided under separate contractual agreements. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. In this case the Care Quality Commission regulates both the premises and the care provided, and both were looked at during this inspection.

Hawkinge House is registered to provide accommodation, nursing and personal care for 115 people. It can accommodate younger adults, older people and people who live with dementia. It can also provide care for people who need support to maintain their mental health and/or who have physical adaptive needs.

Most of the people who were living in the service at the time of our inspection had rented their accommodation in Hawkinge House. All of these people in practice received their nursing and personal care from members of staff employed by Hawkinge House Limited who was the registered provider. A small number of people received both their accommodation and care as part of a single package that was also delivered by the registered provider.

There were 89 people living in the service at the time of our inspection. The accommodation was provided on four floors called Nightingale, Eden, Phoenix and Jasmine. Each person who lived in the service had their own bedroom with a full ensuite bathroom.

There was 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 2008 and associated regulations about how the service is run. In this report when we speak about both the company and the registered manager we refer to them as being, ‘the registered persons’.

At the last comprehensive inspection on 20 July 2017 the overall rating of the service was, ‘Requires Improvement’. We found that there were two breaches of regulations. The first breach was because the registered persons had not reliably ensured that people who lived in the service consistently received safe care and treatment. The second breach was because the registered persons did not have robust systems and processes in place to assess, monitor and improve the quality and safety of the service. This shortfall had resulted in problems in the provision of safe care and treatment not being quickly identified and resolved.

We told the registered persons to send us an action plan stating what improvements they intended to make and by when to address our concerns and to improve the key questions of 'Safe' and ‘Well led' back to at least, 'Good'. After the inspection the registered persons told us that they had made the necessary improvements.

At the present inspection we found that sufficient steps had still not been taken to address either of these breach

This inspection took place on 20 and 21 July 2017 and was unannounced. Hawkinge House is a purpose-built modern building and provides accommodation and nursing care for up to 80 people; a total of 92 people can live and receive support within the same building. The service also provides personal care and nursing care for people who rent or buy their accommodation within Hawkinge House. There were 86 people living at Hawkinge House during our inspection; of which 17 were receiving accommodation and nursing care. The service provides nursing care on the ground floor, the first and second floors support adults living with dementia or mental health needs, some of whom also require nursing.

The service has a registered manager, who was present throughout 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 and associated Regulations about how the service is run.

Hawkinge House was last inspected in November 2016 where a number of breaches of the regulations were identified and it was rated Requires Improvement. The provider sent us an action plan to tell us what actions they were taking to implement those improvements. At this inspection we found that changes had been implemented to address the issues and improvements had been made. However, there were a small number of issues which still required further attention.

Accidents and incidents were reported and responded to in most cases. However, there were occasions when responses did not take place in a timely manner.

Management oversight of the service had improved since our last inspection. Most audits and checks had been effective in identifying and remedying shortfalls, however improvement was further input was needed in some areas. Feedback had been sought from people, relatives and staff.

Risk to people had been assessed. Care plans, risk assessments and guidance were in place and gave staff sufficient knowledge to support people in an individual way. Overall, assessed risks to people's health, such as monitoring food and fluid intake were consistent although this continued to require improvement.

The management of medicines had improved, people received their medicines safely. Policies and procedures were in place but on one occasion staff responsible for administering medicines did not follow these.

Staff knew how to keep people safe from abuse and neglect and the manager referred most incidents to the local safeguarding authority. The safety of the premises was assured by regular and routine checks on utilities and equipment. Fire safety had been addressed through training, drills and alarm testing. Maintenance had been carried out promptly when repairs were needed.

People had a choice of nutritious meals, snacks and drinks, and could choose where they would like to eat. Staff encouraged people to eat their meals and gave assistance to those that required it. Some recording of people’s intake needed improvement to ensure it was clear and consistent.

There were enough staff on duty and they had received relevant training and supervision to help them carry out their roles effectively. Staff were observed putting their training into practice in a safe way. A dependency tool had been introduced to enable to registered manager to assure themselves that staffing levels remained adequate. Recruitment files contained all the required information about staff.

A range of professionals were involved in people’s health care and individual plans of care were in place if people had specific health needs like Diabetes, catheters or pressure wounds.

Staff and managers worked within the principles of the Mental Capacity Act 2005 (MCA) which ensured people’s rights and wishes were protected.

Staff treated people with kindness, compassion

This inspection took place on 9 and 10 November 2016 and was unannounced. Hawkinge House is a purpose-built modern building and provides accommodation and nursing care for up to 80 people; a total of 92 people can live and receive support within the same building. The service also provides personal care and nursing care for people who rent or buy their accommodation within Hawkinge House. There were 87 people living at Hawkinge House during our inspection; of which 22 were receiving accommodation and nursing care. The service provides nursing care on the ground floor, the first and second floors supports adults living with dementia or mental health needs, some of whom also require nursing.

The service has a registered manager, who was present throughout 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 and associated Regulations about how the service is run.

Hawkinge House was last inspected in January 2016 where a number of breaches of the regulations were identified and it was rated Requires Improvement. The provider sent us an action plan to tell us what actions they were taking to implement those improvements. At this inspection we found that changes had not been fully implemented to address all of the issues, leaving some people exposed to the risk of harm. Further areas of concern were also identified at this inspection.

There continued to be areas of medicines management that required improvement in order to make them safe. Most people received their medicines when they should. There were continued shortfalls in the recording of transdermal patch administration and recording and in medicines that are prescribed to be taken ‘As required’.

Staffing levels were not sufficient to meet people’s needs; assessed levels were not always available on duty. We found recruitment processes were robust.

Essential training had been completed by the majority of staff, and some staff had completed additional training in some topics. Staff told us they were able to request additional training if they wished to develop a particular area of knowledge. Staff were provided with the opportunity to undertake a qualification relevant to their role to further develop their knowledge.

Most people reported to enjoy the food however we found people’s hydration and nutritional needs continued to be monitored inadequately, placing people at risk of not receiving sufficient amounts to eat and drink. People had access to healthcare services however, a lack of effective recording meant advice was sometimes not followed through by staff.

Complaints and incidents were not consistently recorded and monitored in line with policy.

People were kept safe from abuse as staff were aware of safeguarding procedures and we saw these were followed when abuse was alleged or suspected.

Staff treated people with kindness, compassion and respect. Staff took time to speak with the people they were supporting. We saw many positive interactions and people enjoyed talking to the staff. The staff on duty knew the people they were supporting and the choices they had made about their care and their lives, although this was not always reflected in care plans, where there was little reference to people’s preferences and wishes. Social assistants had developed good relationships with people and ensured that a range of activities were available for people if they wished to participate.

People had a choice of meals, snacks and drinks, and could choose where they would like to eat. Staff encouraged people to eat their meals and gave assistance to those that required it.

Staff understood the basic principles of the Mental Capacity Act and knew how to support people who were not able to make their own decisions. People’s rights were p

This inspection took place on 21 and 22 January 2016 and was unannounced. The previous inspection was carried out in June 2014 and there were no concerns identified. Hawkinge House is a purpose-built modern building and provides accommodation and nursing care for up to 80 people. The service also provides personal care and nursing care for people who live on site in rented or owned studio or one bedroom suites. A service charge includes gas, electricity and property maintenance. The fees include the cost of all food, personal laundry and cleaning of the suite. The service provides care to adults who have dementia or mental health needs on the first and second floors. Up to a total of 92 people live and receive support within the same building, at the time of the inspection 90 people were living at Hawkinge House.

The service has a registered manager, who was present throughout 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 and associated Regulations about how the service is run.

People were kept safe from abuse as staff were aware of safeguarding procedures and we saw these were followed when abuse was alleged or suspected. Staffing levels were sufficient to meet people’s needs, however we found recruitment processes were not always thorough and robust.

Medicines were stored securely and safely. People received their medicines when they should but there were shortfalls in the recording of topical creams administration and in medicines that are prescribed to be taken ‘As required’.

People enjoyed the food however we found people’s weight and nutritional needs were not being monitored effectively, placing people at risk of not receiving sufficient amounts to eat and drink. People had access to healthcare services however, a lack of effective recording meant advice was sometimes not followed through by staff.

Most staff treated people with kindness, compassion and respect. Staff took time to speak with the people they were supporting. We saw mainly positive interactions and people enjoyed talking to the staff. On occasions we saw some less caring interactions. The staff on duty knew the people they were supporting and the choices they had made about their care and their lives, although this was not always reflected in care plans, where there was little reference to people’s preferences and wishes. Social assistants had developed a good rapport with people and ensured that a range of activities were available for people if they wished to participate. There were less meaningful activities for those who spent most of their time in bed.

People had a choice of meals, snacks and drinks, and could choose where they would like to eat.

Staff encouraged people to eat their meals and gave assistance to those that required it.

Staff had completed training and were able to request additional training if they wished to develop a particular area of knowledge. Staff were provided with the opportunity to undertake a qualification relevant to their role to further develop their knowledge. There were enough staff to meet people’s needs.

Staff understood the principles of the Mental Capacity Act and knew how to support people who were not able to make their own decisions. People’s rights were protected.

Staff were clear about their roles and felt well supported by the registered manager. Audits and checks were in place but were not always effective in identifying shortfalls or areas for improvement.

We found a number of 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 this report.

The inspection was carried out by one Inspector over seven hours. During this time we talked with seven people who were living in the home on the ground floor and with whom we were able to have meaningful conversations. We met many other people living in the home on the first and second floors, and who had dementia, and we observed staff carrying out care duties with them. We talked with nine staff and one relative. The manager was present throughout the inspection and assisted us by providing documentation for us to view.

We looked at the answers to five questions: Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

Is the service safe?

We viewed all areas of the home, including some of the bedrooms. The home was clean in all areas and provided a pleasant environment for the people who lived there. One person said “I am very happy with my room”; and another told us “I have a lovely room”. We saw that some alterations and maintenance work were being carried out to several suites on the ground floor. People living in the home said they had been informed about this. The manager told us that the builders were making sure they provided a safe environment for people living in the home during this work.

We found that the company had comprehensive procedures in place to check that people had consented to the care and treatment provided for them. People who lacked the mental capacity to make decisions about where they lived or the care that they needed had been appropriately supported by their family members or advocates, and by health and social care professionals, to make decisions on their behalf and in their best interests. The manager and staff showed that they understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). The manager said that it had not been necessary to make any applications to deprive someone of their liberty for their own safety.

We talked with some of the staff about safeguarding procedures and they showed that they understood the signs of abuse and knew how to report any concerns or suspicions of abuse. Staff training records confirmed that all of the staff were trained in safeguarding vulnerable adults. The manager demonstrated a clear understanding of how to contact the safeguarding team, and when it was applicable to do so.

Is the service effective?

People living in the home had suitably detailed care plans which covered all aspects of their care and treatment. This included individual needs assessments, and people’s preferences in regards to their care. We saw that people or their representatives had been involved in their care planning.

We found that people were supported by other health and social care professionals to provide them with additional care or treatment as needed.

We saw that the home provided people with a good range of foods to meet their dietary needs. Most dishes were home-made and included home-made soups and cakes every day. Fresh fruit and snacks were made readily available throughout the day. We saw that staff actively offered hot and cold drinks to people on a regular basis. People told us “The food is lovely”; and “The food is really good”.

We looked at staff training records and found that the home encouraged staff to take formal training such as Diplomas and Qualification Credit Framework (QCF) training. Most care staff had been trained or were studying for levels 2 or 3 in health and social care. Other staff had training relevant to their job roles such as catering or management qualifications. There was on-going training in required subjects to ensure staff were kept up to date.

Is the service caring?

People who were able to talk with us said that they were happy living in the home. People’s comments included: “”I am looked after very well. The staff do a very good job, I feel cared for here”; and “It’s perfect here, the staff are very good.” Another person said “There are always lots of activities here – too much! So many to choose from.”

We spent a time of observation in one of the lounges for people with dementia, and we saw that staff spoke kindly to them and had caring attitudes. The staff noticed if people were agitated or wandering in a confused manner, and knew how to gently distract them. We saw that they did not rush people, but listened to them, and tried to show understanding and empathy with them.

We saw that some care plans showed that people preferred the same gender of staff when being supported with personal hygiene care. Staff were aware of this, and adhered to it.

People’s care planning included life histories, so that the staff could appreciate people’s previous lifestyles and hobbies, and be informed about their families and previous occupations. This enabled the staff to speak knowledgably to people with dementia, and help them to feel settled.

Is the service responsive?

The home employed a social assistant on each floor to arrange activities in line with the people’s preferences on that floor. We saw that activity plans were in place for the week, but were flexible in accordance with people’s wishes. For example, the day of our inspection was warm and sunny, and staff offered people the opportunity to sit outside in the afternoon for a tea party. Other people were taking part in gardening activities.

The staff encouraged people to take part in meal times or activities so as to prevent them from becoming socially isolated. However, they also respected people’s decision to stay in their own rooms. Social assistants or care staff visited people who stayed in their own rooms, for individual conversation or activities during each day.

People were able to raise concerns or ask questions and were confident that they would be listened to and that suitable action would be taken to address their concerns. The manager had arranged for a recent telephone survey to take place with people’s relatives. This provided the opportunity for family members to share their thoughts about the home, which was especially beneficial for people who had dementia.

The manager’s office was in a prominent position adjacent to the reception area, and he had an open door policy. This meant that he was easily accessible to people when visiting their friends and relatives.

Is the service well-led?

The provider had systems in place for monitoring the home using weekly and monthly checks and audits. These included health and safety checks, medication audits, care plan audits, accident and incident reporting, pressure sore audits, and checks for unplanned hospital admissions. This enabled the manager to be informed about people’s nursing and personal progress, and identified any trends in different areas of the home.

We observed that staff on each floor worked well together and interacted appropriately with people living in the home. Nursing and care staff were given different areas of responsibility, which enabled them to be more fully involved in the running of the home, and helped them to develop different competencies. We saw that staff were motivated to carry out their different roles. Several staff made comments such as “I love working here”, and “This is the best place where I have worked.”

We saw that the manager was easily accessible to people living in the home, and staff and relatives. He took part in some of the nursing duties and staff training, which meant that staff were confident in his knowledge, abilities and leadership.

We spoke with 11 people living at the service, 12 relatives and 15 members of staff.

People we spoke with were happy with the care and support received. One person commented “It is very pleasant living here, I have everything I need”. Another person told us “The staff are approachable, I feel able to speak with all of the staff about my care and I feel safe when they support me”.

Relatives we spoke with were complimentary of all of the staff, one visitor told us that the staff were very caring and seemed competent and confident when supporting their relative.

During our inspection we saw that people were being spoken with and supported in a sensitive, respectful and professional manner.

The dinning areas on all three floors did not promote a homely environment or help aid orientation for people who had dementia. Tables did not contain condiments for people to be able to help themselves.

We saw that preparation was underway to install a tropical fish tank in the communal lounge on the top floor and staff told us that areas of the service were to be redecorated in bright colours to create a more interesting and stimulating environment for people living at the service.

People we spoke with said they were happy with the way the service manages their medicines. One person told us that staff were "Very kind" when giving them their medicines. We heard people being asked if they were ready to take their medicines and if they wanted any pain killers.

People were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place for the storage and recording of medicines. There was insufficient guidance for staff on the use of some medicines and risk assessments were not in place where necessary.

During our inspection we spent time observing the interactions between people who used the service and staff and the daily routines to help us see how people experienced life in the service.

We used the Short Observational Framework for Inspection (SOFI) during our

inspection. SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us. Our observations showed that people had mixed experiences depending on which unit they lived on and how many staff were available to spend time supporting them.

We spoke with 22 people who were living in the service . Most people we spoke with told us they liked living at Hawkinge House. One person told us how this service was much better than their previous services they have used because they were able to choose how to spend their day. For example listen to music or watch television all day and did not have to cook or clean for themselves.

However, three people told us that they did not like living at Hawkinge House because they felt they had lost their independence when they moved to the service. One person said, “We cannot live independently here, we cannot even cook for ourselves". Another person said, "I have no choice of care here, I just have to have who is on when I need care".

People consistently told us that staff were polite, kind and caring. However, some people told us how difficult it was to understand staff who’s first language was not English. They told us that some staff spoke in their native language between themselves, which they could not understand.

We spoke with 15 members of staff. Staff told us that sometimes they were short staffed on the first floor dementia unit. A relative commented, "There was a big staffing shortage, but it seems to be getting resolved".

We spoke with five relatives who had variable feedback about the standards of care their relative received. One relative told us that when they have visited, their relatives clothes have often looked “grubby” and “dirty” and they have to ask staff to change their relative’s clothes. Another relative told us, "Mum is always clean here and it's 100 times better than the previous home she was in".

People were satisfied with their care and support. Some people said they were involved in decisions about their care. People felt safe using the service. People told us staff were polite, kind and caring. People were given opportunities to say what they thought about the service. Staff told us that sometimes they were short staffed on the first floor dementia unit.