This inspection took place on 9 May 2017 and was unannounced. At the last comprehensive inspection of the service on 25 October 2016 we rated the home as Requires Improvement due to a breach in Regulation 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014: Good governance. This was because, although the registered provider had implemented improvements since an inspection in June 2016, there was a lack of management oversight to ensure the measures had been sustained and were consistent across all areas.

At this inspection we found that governance had improved, quality audits had taken place to identify any shortfalls and action had been taken to address the shortfalls. Recording in care plans and risk assessments was consistent, including records of people’s nutritional needs.

The home is registered to provide accommodation and care for up to 30 older people and younger adults with varying needs that include learning disabilities, autistic spectrum disorder and / or mental health. On the day of the inspection there were 19 people living at the home. The home is situated close to the centre of York. the main house has two floors; there is no passenger lift so people who are accommodated on the first or second floors have to be able to manage the stairs. There are also some ground floor flats to the rear of the premises.

The registered provider is required to have a registered manager in post and on the day of the inspection there was no manager registered with the Care Quality Commission (CQC). 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 new manager had been appointed on 13 March 2017 and they had commenced the registration process with CQC.

Care plans included information to guide staff on how to meet people’s assessed care and support needs. There were some minor anomalies in care plans but this had not affected people’s well-being or the support people had received.

People were protected from the risk of harm or abuse because there were effective systems in place to manage any safeguarding concerns. Staff were trained in safeguarding adults from abuse and understood their responsibilities in respect of protecting people from the risk of harm.

There was evidence that the registered provider was working within the principles of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). No-one living at the home had a DoLS authorisation in place but the registered manager had submitted applications that were being considered by the local authority.

There were recruitment and selection policies in place and these had been followed to ensure that only people considered suitable to work with vulnerable people had been employed. On the day of the inspection we saw that there were sufficient numbers of staff employed to meet people's individual needs.

Staff told us that they were well supported by senior managers. They also told us they received the training they needed to carry out their roles effectively, including training on the administration of medicines. This was confirmed in the records we saw.

We checked medication systems and saw that medicines were stored, recorded and administered safely.

People who lived at the home told us that staff were caring and that staff respected people's privacy and dignity. We saw that there were positive relationships between staff and people who lived at the home, and that staff had a good understanding of people's individual care and support needs.

Activities were provided and people were encouraged to take part, although some people told us they preferred the trips out to the activities provided within the home.

We saw that people's

The inspection took place on the 24 October 2016. The inspection was unannounced. At our previous inspection of the service on the 03 and 08 February 2016, we identified nine breaches of the legal regulations set out under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Five of the identified breaches, which included Regulation 11(Need for consent), Regulation 14 (Meeting nutritional and hydration needs), Regulation 15 (Premises and equipment), Regulation 18 (Staffing) and regulation 17 (Good governance) were assessed as having a low service impact and we dealt with these by issuing a requirement for improvement notice to the registered provider. The registered provider sent us an action plan that contained information on how they intended to meet those regulations and achieve compliance, which was checked during this inspection and we found this action has been completed for these breaches with the exception of Regulation 17 (Good governance) where we identified a continued breach in regulation.

The four remaining breaches were assessed as having a moderate service impact and we dealt with these by issuing the registered provider with a written Warning Notice for improvement for each breach. The breaches we dealt with in this way were Regulation 9 (Person centred care), Regulation 10 (Dignity and respect), Regulation 12 (Safe care and treatment) and Regulation 13 (Safeguarding service users from abuse and improper treatment). A planned focused inspection was completed on the 20 and 21 June 2016 and at that time we found improvements had been implemented and the warning notices were met.

Holgate House provides accommodation for up to 30 older people and younger adults with varying needs that include care and support for learning disabilities, autistic spectrum disorder and/or mental health. At the time of our inspection there were 18 people receiving a service.

Holgate House did not have a registered manager. The previous registered manager submitted an application to cancel their registration to manage all regulated activities and have their registration removed on 15 January 2016. 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 2008 and associated Regulations about how the service is run. The inspection was facilitated by the commercial director. The commercial director told us they had successfully recruited to the post of manager and once the required pre-employment information checks had been completed for the individual they would be submitting an application for the manager to be registered with the Care Quality Commission. .

Despite the improvements and implementation of systems and processes that helped to identify manage and mitigate risks to people, we found that improvements were not consistent or sustained. Where avoidable risks had been identified in people’s care plans this information was not always up to date, or reflective of people’s current needs. Where reviews had been completed, the information was not available in people’s care plans as a point of reference for care workers and other health professionals involved with peoples care and support. Guidance was not robust to help people remain safe from avoidable harm. This meant systems and processes to assess, prevent and raise awareness of risk to provide a basis for appropriate support by staff were found to require further improvement.

Where the registered provider had concerns about people’s capacity or where a Deprivation of Liberty Safeguards (DoLS) had expired, referrals had been submitted to the local authority for further assessment under the Mental Capacity Act 2005. However, information on mental capacity assessments was not available in all care plans for people and there was not

The inspection took place on the 20 and 21 June 2016. The inspection was unannounced. At our previous inspection of the service on the 03 and 08 February 2016, we identified nine breaches of the legal regulations set out under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Five of the identified breaches included Regulation 11(Need for consent), Regulation 14 (Meeting nutritional and hydration needs), Regulation 15 (Premises and equipment), Regulation 17 (Good governance) and Regulation 18 (Staffing). These breaches were assessed as having a low service impact and we dealt with these by issuing a requirement for improvement notice to the registered provider. The registered provider sent us an action plan that contained information on how they intended to meet with those regulations and compliance with these regulations will be inspected at our next comprehensive inspection.

The four remaining breaches were assessed as having a moderate service impact and we dealt with these by issuing the registered provider with a written Warning Notice for improvement for each breach. The breaches we dealt with in this way were Regulation 9 (Person centred care), Regulation 10 (Dignity and respect), Regulation 12 (Safe care and treatment) and Regulation 13 (Safeguarding service users from abuse and improper treatment). This inspection was planned to focus on whether improvements had been made by the registered provider to rectify the four breaches dealt with by way of written Warning Notices only.

This report covers our findings in relation to the Warning Notices. You can read the report from our last comprehensive inspection by selecting the 'All information’ and searching for Holgate House on our website at www.cqc.org.uk.

Holgate House is a care home service without nursing. The service provides accommodation for up to 30 older people and younger adults with varying needs that include care and support for learning disabilities, autistic spectrum disorder and/or mental health. At the time of our inspection there were 19 people receiving a service. Holgate House is located in the historic city of York with good public transport links. Off road parking is available at the rear of the building for visitors.

Holgate House did not have a registered manager. The registered manager submitted an application to cancel their registration to manage all regulated activities and have their registration removed on 15 January 2016. 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 2008 and associated Regulations about how the service is run. At the time of our inspection, we were supported by the nominated individual and the commercial director who were running the service.

We saw that all care workers had now received up to date safeguarding training. The registered provider had a policy and procedure in place for safeguarding vulnerable adults. Care workers were aware of types of abuse to look out for and knew how to report their concerns. People told us they felt safe. This meant people were being protected from abuse and improper treatment. We saw these changes resulted in the registered provider meeting the breach of regulation, previously identified in the Warning Notice for Regulation 13 Safeguarding service users from abuse and improper treatment, under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Systems and processes for risk assessments, prevention of risk and awareness of risk were found to have been updated. Risk assessments had been completed for people and we saw these were documented and reviewed in people’s care plans. We saw care plans included information to help people evacuate the service in the case of an emergency. Fire checks were robust

The inspection took place on the 01 February 2016. The inspection was unannounced. This was the first comprehensive inspection for this registered provider since they took over the home in November 2015.

Holgate House is a care home service without nursing. The service provides accommodation for up to 30 older people and younger adults with varying needs that include care and support for learning disabilities, autistic spectrum disorder and/or mental health. At the time of our inspection there were 19 people receiving a service. Holgate House is located in the historic city of York with good public transport links. Off road parking is available at the rear of the building for visitors.

Holgate House did not have a registered manager. The registered manager submitted an application to cancel their registration to manage all regulated activities and have their registration removed on 15 January 2016. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People provided us with a mixed response about the support and care they received. It was clear from talking with people and looking at care plans that care was not person centred and we saw that people who used the service, their relatives and friends did not contribute to people’s care planning. This was a breach of Regulation 9: Person centred care under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People told us they felt safe, but they told us they had concerns around their safety and the staff who cared for them. Where people had raised concerns with the registered provider regarding their safety, these had not been addressed.

Staff had not all received up to date training in safeguarding adults from abuse and some staff when asked, were unable to identify all the types of abuse they should look out for when caring for and supporting people. This meant that people were not protected from abuse and improper treatment. This was a breach of Regulation 13: Safeguarding service users from abuse and improper treatment.

Care plans had not been updated and staff that supported people did not have access to up to date information on people’s current needs. Although some of the risk assessments we looked at were up to date, we saw these were inconsistent with their care plans and other assessments and that resulting actions had not been carried forward. There was no evidence of how people were being supported or how their risks were being monitored to keep them and others safe.

The above issues meant people were not receiving care and support in a safe way appropriate to their needs. This was a breach of Regulation 12: Safe care and treatment under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The service had a recruitment policy. However, low staffing levels were identified as a serious concern by staff, people and others. The registered provider told us that they did not use a staffing dependency tool and we saw there was insufficient staff, who lacked the appropriate knowledge and skills to meet people’s changing needs and to keep them safe. This was a breach of Regulation 18: Staffing under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We checked the recruitment records for nine staff. We saw that staff had completed an application form that included an equal opportunities statement. Files contained two references and checks had been made with the Disclosure and Barring Service (DBS).

We saw that although the registered provider had a training matrix in place and had implemented a training programme for staff, not all training for staff was up to date. Where gaps in training had been identified there