This inspection took place on 9 August 2017 and was unannounced. The previous inspection was carried out in June 2016 and some concerns around care records, minimising risk and environmental checks were identified. At this inspection we found that improvements had been made.

Hothfield Manor Acquired Brain Injury Centre is registered to provide accommodation with personal and nursing care for up to 45 adults with an acquired brain injury. The service is divided into three areas. The Neuro-Rehabilitation Unit (NRU) provides short term specific rehabilitation; the Manor House provides long term care; and seven Bungalows, which are not currently in use. The provider has said that they don’t plan to re use them at the moment, not at least until they have been refurbished. At the time of the inspection there were 17 people living at the service. 13 in the Manor House and four in the NRU.

People were living with a range of care and nursing needs, some people needed support with all of their personal care, and some with eating, drinking and mobility needs. Other people were more independent and needed less support from staff. People's bedrooms were provided over two floors, with a passenger lift in-between. There were sitting/dining rooms on the ground and first floors. On the ground floor there was also a hydrotherapy pool, a gym and an adapted daily living skills kitchen. Outside there was an enclosed garden and large grounds which people could access.

At this inspection, records, both electronic and paper, were in good order and contained current information that was clearly laid out; making them easy to use. Risks had been properly assessed and environmental checks had been completed in line with current guidance.

The service had 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.

Medicines were managed safely and people received their medicines when they should. People were supported to maintain good health and attended appointments and check-ups. Health needs were kept under review and referrals were made when required. People were supported in a safe environment and risks had been identified, and were managed in a way that enabled and encouraged people to live as independent a life as possible.

Staff understood how to protect people from the risk of abuse. They had received safeguarding training and were aware of how to recognise and report safeguarding concerns. Staff knew about the whistle blowing policy and were confident they could raise any concerns with the provider or outside agencies if needed.

Equipment and the premises received regular checks and servicing in order to ensure it was safe. The registered manager monitored incidents and accidents to make sure the care provided was safe. Emergency plans were in place so if an emergency happened, like a fire, the staff knew what to do.

A robust system to recruit new staff was in place; this helped to make sure that people were supported by staff that were fit to do so. Throughout the day and night there were sufficient numbers of staff on duty to meet people’s assessed needs. When staff first started to work at the service they were supported to complete an induction programme. Staff continued to be supported with ongoing training, support and supervision. Staff meetings took place. These all gave opportunity for staff to share ideas and discuss any issues.

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards. The registered manager and staff showed that they understood their responsibilities under the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safegu

This inspection took place on 28, 29 June and 1 July 2016 and was unannounced.

Hothfield Manor Acquired Brain Injury Centre provides accommodation with personal and nursing care for up to 45 adults with an acquired brain injury. The service is divided into three areas. The Neuro-Rehabilitation Unit provides short term specific rehabilitation; the Manor House provides long term care; and seven Bungalows, which are not currently in use. At the time of the inspection there were 21 people living at the service.

People were living with a range of care and nursing needs, many people needed support with all of their personal care, and some with eating, drinking and mobility needs. Other people were more independent and needed less support from staff. People's bedrooms were provided over two floors, with a passenger lift in-between. There were sitting/dining rooms on the ground and first floors. On the ground floor there was also a gym and an adapted daily living skills kitchen. There was a swimming pool, which was not in use due to on-going repairs. Outside there was an enclosed garden and large grounds which people could access.

The service had a newly appointed registered manager who was available on the days of the inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Hothfield Manor was last inspected on 29 and 30 December 2015.They were rated as inadequate overall at that inspection and placed into Special Measures. The provider sent us regular information and records about actions taken to make improvements following our inspection. At this inspection we found that significant improvements had been made in most areas. In others, however, there were still some improvements required.

People's safety was not always protected due to safety checks not being routinely undertaken. Equipment was serviced at required intervals.

People enjoyed the food however we found people's weight, and hydration 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.

Risks to people and guidance for staff were not always recorded accurately. People were protected from the risk of abuse. Staff had received safeguarding training. They were aware of how to recognise and report safeguarding concerns. Staff knew about whistle blowing and were confident they could raise any concerns with the provider or outside agencies if needed.

Feedback, in the form of quality surveys was not sought from people, their relatives or professionals. This meant that opportunities to improve the service could be missed.

Electronic records were not easily accessible, or consistently recorded. Audits took place but were not always effective in identifying shortfalls or required actions.

People did not always receive support that met their needs. The care and support needs of each person were different, and each person’s care plan was personal to them. People had detailed care plans, risk assessments and guidance in place to help staff to support them in an individual way.

Medicines were well managed. Staff followed correct and appropriate procedures in the storage and administration of medicines.

There were enough staff deployed to meet people's needs and they had received appropriate training and supervision to help them carry out their roles effectively. Staff were caring and responsive to people's needs and interactions between staff and people were warm and respectful. Recruitment processes had been followed to ensure staff were suitable for their jobs.

Staff had comp

We carried out this inspection to follow up compliance actions given at our previous inspection in May 2014. At the previous inspection we found that the storage and management of medicines was unsatisfactory in each of the three units; and this had not been identified as part of medicines’ audits.

This inspection was carried out by one Inspector over two hours. During the visit we talked with the manger about the changes that had been put in place for medicines storage, and the changes that were due to be implemented. We also talked with five staff, and two people living in the service.

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 saw that the premises were visibly clean and satisfactorily maintained. We viewed the three areas where medicines were stored, and saw that medicines were stored safely. In the Manor House, the staff had noticed that the room temperature where medicines were stored sometimes rose higher than 25 degrees Centigrade. This meant that that some medicines could become less effective if they were not always stored at the correct temperatures. The staff had arranged for the medicines trolley to be stored temporarily in the Neuro-Rehabilitation Unit clinical room at these times, to protect the medicines. This showed that staff were aware of the importance of safe storage.

Is the service effective?

We viewed the processes for receipt and disposal of medicines, and the records for administration. These demonstrated that medicines were correctly checked in, and were administered to people in accordance with their prescriptions.

The company had recognised that auditing procedures for medicines needed to include an assessment of safe storage, and they were reviewing auditing processes.

Is the service caring?

Medicines’ records showed that people were given prescribed medicines correctly. We saw that pain assessment charts were used to remind staff of the people who might be experiencing pain, and to offer them pain relief as needed. Some people had ‘as necessary’ (PRN) medicines. We saw that clear directions were given for administering these medicines, and the reasons were clearly recorded.

People who were making significant progress with managing their own care were assessed for their ability to manage their own medicines. This showed that staff enabled people to be as independent as possible and to take increased responsibility for their own treatment.

Is the service responsive?

The service ensured that people’s medicines were reviewed by their GP or other suitable health professionals on a regular basis. People who were experiencing difficulties in their behaviour were referred to the mental health team for re-assessment, including a review of their medicines.

Is the service well-led?

The manager informed us that the company which owned the service had recognised that their monthly auditing processes for medicines management did not include medicines’ storage. The company were in the process of reviewing this documentation.

The manager told us that improvements in storage in two of the units had not yet been implemented. This showed a disappointing time delay, but we saw purchase orders and installation orders for the work that was to be done to improve the storage facilities. The manager had contacted us prior to this inspection to inform us of the company’s action plan for improved storage; and had told us that the service was waiting to hear from the estates manager for a date when the work would be carried out.

The service had processes in place to take people’s views into account, and to take action as a result of their comments.

The inspection was carried out by one Inspector for over eight hours. During this time we viewed all three of the units. We met and talked with six people who were living in the centre; talked with four relatives; and talked with 16 of the staff on duty. The manager was not available, but the deputy manager was present throughout the day. Other staff that we talked with included nurses, physiotherapists, a psychologist, a speech and language therapist, support workers, a rehabilitation assistant, a housekeeper and an activities organiser.

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 found the service was not always safe because although medication administration was managed appropriately, medication storage was unsatisfactory in each of the three units, and required improvement.

We saw that the centre had reliable assessment processes in place prior to admitting new people. Care plans contained comprehensive details to instruct the staff in the individual care that people needed. They included risk assessments for maintaining people’s safety and security.

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). One person currently had a Deprivation of Liberty Safeguard authorisation put in place. Applications had been made on behalf of other people living in the centre as necessary.

Is the service effective?

We found that people's care needs were thoroughly assessed, and reflected the individual care that people needed. The home provided a good variety of different types of equipment that enabled people to develop their physical and co-ordination skills, and assisted them to become more independent.

We found that health professionals providing health care had specific knowledge about their areas of work, and were able to support people in making progress with their health needs. The staff recognised people's changing health needs, and were quick to make referrals to additional health staff if the person's condition indicated this was appropriate.

Two people in the Neuro-Rehabilitation Unit were able to tell us that they had made significant progress with their health needs since their admission, and were really pleased about this. Relatives that we spoke to said that "There is a clear focus on rehabilitation, and X has done very well since moving in here.”

We saw that people were assisted as necessary in maintaining an adequate food and fluid intake. This included medical intervention using "PEG" feeding; and staff assisting people to eat and drink where they needed support.

We saw that the service provided the different levels of health care, rehabilitation and support that people needed at different stages of their recovery and development. This showed that the service was effective in the support it provided.

Is the service caring?

People we spoke with said that the staff were very helpful and kind. They said that the staff answered their call bells promptly and their requests for help. One person said that when they rang their call bell that the staff would arrive quickly and say “What can I do to help?” Another person said: “They look after me fine”. We observed that staff spoke to people in a gentle and caring manner and did not rush them.

The centre provided a wide range of activities for people to take part in. This included subjects which helped people to regain their independence, such as preparing drinks and meals, and managing their laundry. Other activities included leisure pursuits such as a gardening club, quizzes and film afternoons, and going out of the centre. Each person in the Manor House unit was enabled to go out of the centre with staff support at least once per week. This included shopping trips, and visits to places such as the beach, and the local attraction of Leeds Castle.

Is the service responsive?

We looked at six people's care plans and saw that they were reviewed and amended in line with people's changing needs.

We saw that the home provided people with different types of activities according to their abilities, their health needs and their preferences.

People receiving care said that if they raised any concerns they were confident that appropriate action would be taken.

We looked at staff training records and saw that the staff received mandatory training in relevant subjects and were able to take further training if it was in line with their job roles.

Staff said that they felt well supported by each other and worked well as teams. They met together in the units for regular meetings so as to discuss people’s ongoing needs and ensure their care and support was suitable for their individual needs.

Is the service well-led?

The manager was not present on the day of the inspection, but we saw that the deputy manager was well known by the staff and people living in the home. He provided leadership for the staff and took part in practical skills and meeting people’s care needs, as well as carrying out other management duties.

We found that the centre had processes in place for obtaining people’s views. This included the use of questionnaires, and residents’ meetings.

The deputy manager told us that the manager and staff carried out monthly audits which were sent to the company’s head office for quality control checks. These included care plan audits, medication audits, health and safety and environmental audits and an infection control audit. We viewed some of the medication audits and saw that these had been carried out in accordance with the questions on the audit. However, the auditing processes had failed to identify the unsuitable storage for medication in each area of the centre, showing that the auditing processes were not fully effective. Staff in each unit said that they had verbally raised their concerns about the medicines’ storage but “Nothing had been done”. This showed that staff views were not always taken into account and followed through on their concerns.

People experienced care and support that met their needs and ensured their safety and welfare. People told us they were happy with the care and support they received and said “Everything has been handled very well and professionally and people have been friendly, it’s more than I could ask for”.

People were protected from the risk of abuse. The manager described some concerns and the action planned and taken to protect people.

People benefitted from safe and comfortable accommodation. People told us “The place here and the surroundings are really lovely.” We saw that each area of accommodation was suitable for the differing needs of people who used the service. The Neuro-Rehabilitation Unit contained a number of dedicated therapy areas for people to use.

People who used the service and their relatives were asked for their views about the care provided and these were acted on. People told us “There is nothing but good to say” and “I’ve got no complaints about anyone.”

People were cared for by staff who were supported by supervision to deliver care safely and to an appropriate standard. However, not all staff had completed all of the training they needed to meet people’s needs effectively.

We were able to speak with two people that were using the service about their experiences of the care they received. One person said “It is very good here” and another commented “The team here are wonderful, they work really well together and they all do a great job”.

Whilst some people were not able to tell us their views we were able to see that they were experiencing care that met their needs. We saw that people were comfortable with the staff supporting them and were involved in social activities and their planned therapy sessions.

People told us they were happy and liked living at Hothfield Manor. One person told us “I like living here it is nice, the staff are good they help whenever they can”. People were able to make decisions and had control over their day to day lives. One person told us “It is good to do your own washing and cooking. I get a lot of my own input now and I am able to make decisions. I know I can leave whenever I want and I know who to complain to”. Another person told us “I please myself, I like to draw all day. The support workers here are good they know what to do, they encourage you to clean and maintain your own bungalow with support”.

People had access to health care such as opticians, chiropodists, doctors and dentists. One person told us “I’m going to the doctor today”. Another person said “I visit the GP often and my care worker comes with me”.

People were involved in all the day to day decisions within the home. Care plans reflected people’s needs and wishes and were periodically updated. People told us they liked the food and what to eat was decided each day. People’s medicines were handled safely by staff. People were happy with their rooms. The home was homely and appropriately maintained. There were good communal facilities which people enjoyed using.

This inspection took place on 29 and 30 December 2015 and was unannounced.

Hothfield Manor Acquired Brain Injury Centre provides accommodation with personal and nursing care for up to 45 adults with an acquired brain injury. The service is divided into three areas. The Neuro-Rehabilitation Unit provides short term specific rehabilitation; the Manor House provides long term care; and seven Bungalows within the grounds provide support for people who are able to live more independently. At the time of the inspection there were 31 people living at the service.

There was not a registered manager in post. 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 deputy manager (who had worked at the service for 18 months) had taken on the role of acting manager and had been in this current post for six weeks. They were present on the days of the inspection.

People’s safety was being compromised in a number of areas. The arrangements that were in place to safeguard people from the risk of abuse were not adequate as people were frequently suffering harm and not all incidents which should be reported to the local authority and CQC had been. The management of risks relating to people’s health conditions and challenging behaviours were inadequate. This put people at risk of serious harm. Staff did not always understand risk and accidents and incidents were not always recorded and analysed to reduce the risks of further events.

There were not enough staff at all times to meet people’s needs. Recruitment procedures did not ensure that staff employed had the necessary skills and were suitable to work with people. Not all staff had received the necessary training and some training was out of date. There were no systems in place to support staff appropriately, identify their development needs or to check they had learnt from the training. Staff did not always treat people with dignity or respect.

People were not consulted about their care and treatment and were not involved in their care plans. Care plans lacked information about people’s interests and preferences. They were not maintained and did not always reflect the needs of people. People could not rely on care being delivered in a consistent and appropriate way. Where assessments of people’s needs were required they had not always been undertaken. Activity provision was inadequate and people had very little engagement and were at risk of social isolation.

Medicines were not consistently managed safely, handled appropriately, stored safely and securely or disposed of in line with guidance. The provider had a policy in place but staff had not consistently adhered to this. The service was not clean and tidy and was not free from offensive odours.

When people were unable to give valid consent to their care and support, staff did not consistently act in people’s best interest and in accordance with the requirements of the Mental Capacity Act (MCA) 2005. Some staff did not understand or have a good working knowledge of the key requirements of the MCA and how it impacted on the people they supported.

People’s health was not consistently monitored and care and support were not consistently provided to meet any changing needs. Staff did not always know what to do to make sure people had everything they needed.

People’s views on the food varied. The food looked appetising; people ate well and took the time they wanted to eat their meal. Staff took into account people that wanted to eat alone or in their own room.

The provider had a policy in place which gave guidance on how to handle complaints but information given to people included out of date information about who to complain to. Staff were concerned about the quality of the service being delivered. Staff told us they did not feel supported or valued by the management and were not clear about what was expected of them.

There was no clear auditing system in place to monitor the quality of the service being delivered. Records were not in good order or always kept up to date. Records were stored securely to protect people’s confidentiality. Notifications about important event that had happened at the service had not consistently been submitted to CQC in an appropriate and timely manner in line with CQC requirements.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.