We carried out this inspection on 5 and 6 February 2019. The inspection was unannounced.

Homecrest Care Centre is a ‘care home’. People in care homes receive accommodation and nursing or personal care as 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 offers accommodation for people who require support with their personal care. There are 29 single bedrooms with a passenger lift enabling access to bedrooms on the upper floors. Four of these bedrooms are reserved for people who require emergency admission to the home or respite care.

On the day of our visit, 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. At the time of this inspection, the registered manager was absent from work and had been for some time. An interim manager was in post to manage the service in their absence. The interim manager commenced in post in September 2018.

At our last inspection in July 2018 we identified breaches of Regulations 9, 12, 13, and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches related to person centred care, the management of risk, the safeguarding of vulnerable adults and the governance arrangements in place at the home. After the July 2018 inspection, the home was placed in special measures. CQC served a notice to add a condition to the registration of the service with CQC. This condition meant that the home had to seek permission from CQC if they wanted to admit any new person to the home

At this inspection, we checked to see if the provider had acted on the concerns we had identified. At this inspection the standards of care at the home had improved significantly but the provider still had some improvements to make to achieve full compliance with the health and social care regulations. This was because there were continued breaches of regulations 12 and 17 identified again. At the last inspection, the service was rated overall inadequate. At this inspection as a result of the improvements made, the service has been rated ‘requires improvement’.

We found that the majority of people’s needs and risks in the delivery of care were assessed and had suitable management plans in place for staff to follow. Further action was required with regards to the support of one person’s health condition and two other people’s mobility needs. A recent trip out organised for two people who lived at the home had also not been properly risk assessed or managed. These issues meant that the provider had not sufficiently responded to the concerns we identified at the last inspection with regards to risk management.

At the last inspection the management of medication required improvement. At this inspection, the management of medicines had declined further. This placed people’s health and well-being at risk. We found that medicines were not properly accounted for. This meant it was difficult to tell what medicines had been received into the home and whether they had been administered correctly. We spoke with the interim manager about this. They agreed that urgent action needed to be taken to ensure medication management was safe. After the inspection, we referred our medication concerns to the local authority for investigation.

The system in place to identify and respond to potential incidents of abuse had improved to protect people from risk but notifications of potential abuse to CQC had not always been made.

The provider had still not ensured that the home’s electrical installation was certified as safe to use. We drew this to the provider’s a

We carried out this inspection on 20, 30 and 31 July 2018. The inspection was unannounced.

Homecrest Care Centre is a ‘care home’. People in care homes receive accommodation and nursing or personal care as 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 offers accommodation for people who require support with their personal care. There are 29 single bedrooms with a passenger lift enabling access to bedrooms on the upper floors. Four bedrooms are reserved for people who require emergency admission to the home or respite care.

On the day of our visit, 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.

At our last inspection in January 2018 we identified breaches of Regulations 10, 12, 17, 18 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches related to dignity and respect, the management of risk, the safe recruitment of staff, staff training and the governance arrangements in place to manage the home. After the January 2018 inspection, the provider submitted an action plan to CQC outlining the action they intended to take to improve the service.

At this inspection we found that the provider had not taken sufficient action to address all of the breaches we had previously identified in accordance with their action plan. We identified continued breaches of Regulation 12 (safe and appropriate care) and Regulation 17 (good governance), and additional breaches of Regulation 9 (person centred care) and Regulation 13 (safeguarding of people from the risk of abuse and improper treatment). The concerns we identified during this inspection were serious and significant and we were concerned about people’s immediate welfare.

We reviewed seven care records. Risks associated with people’s care were assessed and staff had guidance on how to manage these conditions. Records showed that staff did not always follow the risk management advice in order to protect people from harm. One person’s medical needs were not monitored in accordance with risk management guidelines and two people’s challenging behaviours were not always supported appropriately. At times this had resulted in staff and the person sustaining physical harm due to the use of unauthorised restraint techniques.

We identified that a number of serious safeguarding incidents had not been appropriately reported, investigated or responded to by the manager or provider in accordance with local safeguarding procedures or CQC requirements. This meant that the manager and provider failed to take appropriate action to protect and prevent the risk of people experiencing abuse or improper treatment.

Some people’s bedrooms smelt extremely offensive and it was difficult to comprehend that people still lived in these conditions. Some of the home’s communal areas were also malodorous and unpleasant to be in but despite this no action had been taken by the provider to improve people’s living conditions. The home’s boiler frequently tripped which meant that at times people did not have access to hot water to wash in. On day one of the inspection, there was no hot water in the home when we arrived. Records showed that the temperature at which the home’s water was stored was not sufficient enough to control the risk of Legionella bacteria developing in the water supply. This meant that risks to people’s physical health and well-being were not mitigated against.

People’s medication was stored securely but not always at safe temperatures. This meant there was a risk that some of the medicines were not safe

Homecrest Residential Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Homecrest Residential Home provides accommodation for up to 29 people who require support with their personal care. The home is located in a residential area of Wallasey, Wirral and has a small car park at the front of the home. There are 29 single bedrooms, most of which have en-suite facilities. The bedrooms are situated across three floors. The home’s upper floors are accessible via a passenger lift. On the days we inspected there were 26 people living at the home.

There was a registered manager in post at the time of our 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.’

Prior to this inspection in December 2017, a new nominated individual was appointed for the service. A nominated individual is responsible for supervising the management of the home.

At our last inspection in August 2016, we identified breaches of regulations 12 (safe and appropriate care), 16 (the handling of complaints) and 17 (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. After the August 2016 inspection, the provider submitted an action plan to The Commission outlining the action they would take to improve the service.

At this inspection, we found that although some improvements had been made to address the issues identified in the August 2016 inspection, the improvements undertaken were insufficient. This meant that the service continued to be in breach of regulations 12 and 17. We also identified additional breaches of regulations 10, 11, 18, 17 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This meant that service’s ratings for safe, caring and responsive were downgraded to inadequate for safe and requires improvement for caring and responsive. The overall rating for the service remained unchanged but means that the service has been rated requires improvement for the second time in a row.

During our visit we found that changes in people’s nutritional risks were not always responded to in a timely manner. Staff were recording people’s weights on a monthly basis but failed to identify and address a consistent pattern of weight loss for two people.

Parts of the premises were unsafe and on day one of the inspection parts of the home were also unclean. The window restrictors in place on people’s windows to prevent a fall were of poor quality. The radiator covers in place were not secure and some areas of the home smelt offensively. On day one of our visit, one of the fire exit doors was open but no alarm had sounded to alert staff and one of the home’s fire exits was partially obstructed with mobility equipment. These obstructions were removed by day two of our inspection.

The administration of medication was not always safe. The systems in place to account for the medicines in the home had improved but during our inspection we observed a member of staff sign a person’s medication chart without having observed the person take their medication. One person’s ‘as and when’ required medication plan for anxiety and distress was also not followed.

Staff recruitment procedures were unsafe. New staff employed in 2017 did not have adequate information collated by the manager in respect of their suitability to work in the home prior to their appointment. The information that had been collated had also not been verified. One staff member had been recruited without adequate informatio

Homecrest Residential Home provides personal care and accommodation for up to 29 people. The home is in Wallasey, Wirral. The property is a three storey building with a small car park available at the front. Bedrooms are single occupancy with ensuite toilet facilities. A passenger lift enables access to bedrooms located on upper floors for people with mobility issues. On the ground floor, there is a communal lounge, dining room and conservatory for people who live at the home to use.

The home has 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 2008 and associated Regulations about how the service is run.’

During our visit, we found breaches of three regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulated Activities 2014. These breaches related to the provision of safe and appropriate care, medication management, complaints and the management of the home You can see what action we told the provider to take at the back of the full version of the report.

We reviewed three care records. We saw that care plans contained person centred information about the person and their life prior to coming to the home. Each care plan was holistic and reflected people’s needs and care. Risks associated with people’s care were assessed and staff had guidance on how to manage these conditions to prevent further decline. We found however that professional advice in relation to one person’s nutritional risks had not been appropriately followed up. This meant that staff could not be sure that the support provided was the safest way to manage the person’s nutritional risks. This placed the person at potential risk of harm.

Some of the moving and handling techniques used by staff in support of people’s mobility needs were inappropriate and placed people and staff at risk of accident and/or injury. We asked the manager to address this immediately.

The premises and equipment at the home had been regularly checked and inspected. Records showed persistent faults with the passenger lift and we saw that this had impacted on at least one occasion on the delivery of care. We spoke to the provider about this. They assured us that work was due to take place to resolve this. We found that some of areas of the home were unbearably hot. Elderly people are at increased risk of infection and dehydration in high temperatures. No appropriate action had been taken to ensure that temperatures were monitored and adjusted so that people were protected from any potential health risks arising from unsafe room temperatures.

Medication was given to people in an appropriate and pleasant way but the way in which medication was accounted for at the home was not satisfactory. This meant discrepancies in stock levels and administration errors were not always picked up.

People’s nutritional needs and risks were assessed and planned for. People were given a choice of suitably nutritious meals of sufficient quantity. People told us the food was satisfactory but that a bedtime drink was no longer routinely provided which meant that sometimes the last drink they received was at teatime. This meant there was a risk that some people would go long periods without a drink. We saw that one person required a pureed diet. The way in which this diet was prepared required improvement to ensure their dietary intake was supported in the best way possible. People who required assistance to eat at mealtimes where supported in a patient, sensitive manner by staff.

Where people had mental health issues, care plans contained person centred information to enable staff to understand the person and the impact these mental health issues had on their day to day life. We saw that there were

We considered all of the evidence we have gathered under the outcomes we had

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?

Is the service safe?

People were cared for in an environment that was safe. The home was seen to be clean and hygienic. Equipment at the home was well maintained and serviced regularly. There were enough staff on duty to meet the needs of the people living at the home and a member of the management team was always available on call in case of emergencies.

Staff personnel records we looked at for training, supervision and appraisal. All staff were up to date with their training and told us they were supported by the management team.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. While no applications had been made by the home, proper policies and procedures were in place. Staff were trained to understand when an application should be made, and how to submit one.

Is the service effective?

People told us that they were happy with the care and their needs were met. It was clear from our observations and from speaking with staff that they had a good understanding of people's care and support needs and knew them well. One person told us. "The staff are nice here". Staff had received training to meet the needs of the people living at the home.

Is the service caring?

We spent time in all areas of the home where we observed staff to be kind and patient to the people who lived there. Care staff and nursing staff were patient with people, asking them what they wanted and not telling them, but encouraging them in the right direction. One relative told us "It's a caring place and my relative is looked after by staff ".

Is the service responsive?

People's needs were assessed before they moved into the home. A relative told us that all staff were very attentive and understood what was important to their relative. Records confirmed people's preferences, interests, aspirations and diverse needs were recorded and care and support provided in accordance with people's wishes. People had access to activities that were important to them and were supported to maintain relationships with their friends and relatives.

Is the service well led?

Staff had a good understanding of the ethos of the home and quality assurance processes were in place. A relative told us they had completed a customer satisfaction survey, and if they were unhappy with anything staff would always listen. Staff told us they were clear about their roles and responsibilities. They said the management team always consulted with them before implementing changes to the management of the home and their views were taken into consideration. Staff said "We provide good care and at Homecrest".

We spoke to five people who used the service, out of a possible 29 and spoke with four relatives. Most of the people being cared for had communication difficulties but we saw that people were able to express their wishes by gestures and eye contact. They responded well to staff who were respectful and caring. We spent time observing how people were cared for and saw they looked content and relaxed. We saw that staff checked with people that they were comfortable, explained their interactions and offered them choices such as where they wanted to eat or how they wanted their hair done.

We pathway tracked the records of three people and saw details of discussions with health and social care practitioners such as the falls team, speech and language therapists and GPs recorded in their care records. Staff we spoke with told us they had a good relationship with other professionals who came to visit which meant that a holistic approach was taken to the care provided.

We saw there was a process for ordering, checking and returning medications and we observed medication being administered by staff who were appropriately trained. The manager made sure that staff employed at the home had the appropriate characters and skills required to undertake the role. There was a complaints procedure to follow, which people were aware of and we found that records were maintained appropriately with clear instruction to staff on how each person's care needs should be met.

People who used the service and relatives we spoke with told us they were very happy living at the home, were well cared for and treated with dignity and respect. They told us:

“It’s fantastic”, “Brilliant here”, “They are absolutely wonderful”.

We found evidence that relatives of people who used the service were involved in deciding their care and treatment and were able to make choices in every day living activities. There were plenty of activities that people enjoyed organised by the activity coordinator and included external entertainers, exercise and poetry groups.

We saw that people were well cared for and treated with dignity and respect. People’s needs were assessed, planned and reviewed. We found that the provider monitored the service and gained views on the service from relatives and from people who used the service.

We asked other people who may be involved with this service for information regarding the service and provider. No relevant or concerning information was available from stakeholders that we asked.

We visited the home on 1 November 2011. We spoke to people who use the service and their relatives.

People who use the service told us they were happy living in the home and that they were well looked after. They told us that they were treated with dignity and respect and were encouraged to be independent as much as possible. We were told that staff listen to their views and take them into account. We were told:

“They pay attention to you”, “ they are very receptive to what you have to say”

Relatives that we spoke to told us that they were very happy with their relatives living at the home. They felt they were kept informed all the time and able to have their say in how their relatives were cared for. Some relatives had received written up dates to risk assessments and care plans from the manager when a change in assessment and plan had to take place.

They also told us that they felt able to raise concerns if they needed to.

Relatives expressed their satisfaction with the service and made such comments as:

“absolutely wonderful”, “everyone is very good “