This inspection was carried out on 28 September 2018 and was unannounced. A further visit was carried out on 3 October 2018 which was announced.

At the last comprehensive inspection of this service in August 2017 we found the provider had breached Regulations 11, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. This was because people’s consent had not always been recorded. Also, there were shortfalls in relation to staff training in dementia care; and the provider’s quality assurance system was not effective in monitoring the quality of the service.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions Safe, Effective and Well-Led to at least good. At this inspection we found the provider had made improvements and had addressed these shortfalls. People’s consent was now recorded. Staff had more training opportunities in relevant areas of care. The provider had put in place a schedule of audits as part of its quality assurance check of the service.

Howard Court Care 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.

Howard Court Care Home accommodates up to 28 people in one adapted building. There were 24 people living here at the time of this inspection, including people who were living with dementia.

The home had a registered manager who had worked there for several years. 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 and relatives said the home was a safe and friendly place to live. Staff understood how to report any concerns. The provider carried out checks to make sure only suitable staff were employed. People were assisted with their medicines in a safe way. The home was clean and comfortable.

People told us they were happy with the care and felt there were enough staff to assist them. They told us staff responded quickly to any requests for support. People’s consent and permission was sought. If people were subject to any restrictions to keep them safe, such as giving medicines in a disguised way, this had been arranged in people’s best interests.

Before people moved to the home their needs were assessed to make sure the home could provide the right care. Staff said they had good training and support to care for people in the right way. Staff worked well with other health agencies and people were supported to access health services.

People said the meals were “very good”. They had choices about their meals and where to dine. Staff encouraged people to eat and drink enough and used fortifying drinks to help people to keep their weight up.

People felt the staff were caring and friendly. There were good relationships between people and staff and a warm, positive atmosphere in the home. Staff spoke to people in a respectful and s sensitive way. People’s individual choices were respected and their dignity was upheld. People’s needs were supported with compassion at the end stages of their lives.

People received personalised care that was based on their unique preferences and needs. Staff were knowledgeable about people’s individual care needs and how they wanted to be assisted. People had opportunities to join in activities or go out with staff from time to time.

People, relatives and professionals said the management team were open and approachable. People and staff had opportunities to make suggestions about the service.

The provider had made some improvements to its quality assura

This unannounced inspection took place on 30 August 2017. Howard Court Care Home provides accommodation for up to 28 older people some of whom may be living with dementia. At the time of the inspection 24 people lived at the service.

At the last inspection on 27 and 30 July 2015, the service was rated ‘Good’.

During this inspection we found the service to be in breach of three regulations under the Health and Social Care Act, 2008 (Regulated Activities) Regulations 2014. The breaches were in respect of Regulations 11 seeking consent, Regulation 18 staff training and Regulation 17 good governance. This included shortfalls in the effective implementation and operation of effective quality assurance processes to assess, monitor and improve the quality of the service provided. A failure to seek and record consent and failure to provide staff with ongoing training and development. You can see what action we told the registered provider to take at the back of the full version of the report.

Feedback from people and their relatives regarding the care quality was overwhelmingly positive. Views from professionals were also positive.

People who lived at Howard Court Care Home told us that they felt safe and there was sufficient staff available to help them when they needed this. Visitors and people who lived at the home spoke highly of the registered manager and the owner who is also the provider. They told us they were happy with the care and treatment.

People had received their medicines as prescribed and staff had been trained in the safe management of medicines. However, we found areas that required improvement in the medication administration records. The registered manager and the registered provider took immediate action to make the required improvement soon after the inspection. Medicines were stored securely to ensure they were safe.

The registered manager understood the requirements of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). People’s consent to various aspects of their care was considered and where required DoLS authorisations had been sought from the local authority. However the systems for assessing and recording to mental capacity assessments were not in place. The registered manager took action immediately after the inspection and made the required improvements to the documentation.

The registered manager had systems in place to record safeguarding concerns, accidents and incidents and take appropriate action when required. Recruitment checks were carried out to ensure suitable people were employed to work at the home. We noted that the recruitment policy needed updating to ensure it was in line with current legislation. Our observations and discussions with staff and people who lived at the home confirmed sufficient staff were on duty.

Risk assessments had been developed to minimise the potential risk of harm to people who lived at the home. These had been kept under review and were relevant to the care and support people required. Risk associated with fire had been managed and fire prevention equipment serviced in line with related regulations. However people did not have personal emergency evacuation plans in their files. This was resolved immediately by the registered manager.

Care plans were in place detailing how people wished to be supported. People who received support, and their relatives, told us they were involved in their care planning. However, this had not always been recorded. People’s independence was promoted.

The provider had sought people’s opinions on the quality of care and treatment being provided. Relatives and residents meetings and surveys had been undertaken to seek people’s opinions. However the surveys had not been analysed and feedback provided to people on the outcome of the surveys.

We observed regular snacks and drinks were provided between meals to ensure people received adequate nutrition and hydration. People’s nutritional needs

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

• Is the service caring?

• Is the service responsive?

• Is the service safe?

• Is the service effective?

• Is the service well led?

This is a summary of what we found-

Is the service safe?

We saw that the staff team had not been trained to cope with challenging behaviour and that behavioural planning was inadequate. People in the home and the staff were not always safe when supporting people who found managing their emotions and behaviour difficult.

We also discovered that some incidents in the home had not been reported to the local authority as safeguarding. A number of staff needed updates to their safeguarding training. Some recruitment and disciplinary matters needed improvement.

We looked at the environment and found problems with fire safety, infection control and general cleanliness. Some equipment and furniture needed to be repaired or replaced. We saw a number of potential health and safety hazards around the home.

Is the service effective?

We found that the care planning in the service did not meet people's needs in an effective way. For example care plans did not give effective strategies for managing nutritional needs or challenging behaviour.

We had evidence to show that there were not enough staff to cover all the care, housekeeping, catering and social care needs in the home. We also judged that more training, supervision and appraisal was needed so that staff could meet the needs of the people in the home. We had evidence to show that further developments were needed so that dementia care and safeguarding were being dealt with appropriately.

Is the service caring?

We saw a number of caring and sensitive interactions between staff and people in the home. People told us that the team were:

"Lovely...very caring."

We had a lot of comments about the way the manager tried to understand everyone's needs and one visitor said:

"The manager is very good and understands all my partner's needs. She is always around and is a very caring person."

However because of the issues with safeguarding and care planning we judged that despite the caring attitude of staff some people were not being adequately cared for.

Is the service responsive?

We found very little evidence to show that people were involved in care planning. We judged that this meant that individual needs were not always responded to appropriately.

On the day we did see that staff tried to respond to need but that sometimes this was difficult because staffing levels were not appropriate.

Is the service well-led?

People in the home knew the manager well and felt they could trust her. A number of people said they would go to her or to the provider if there were any concerns or problems.

We saw that the manager had made a good attempt to update some of the paperwork around care planning. We also had evidence of her work with staff who needed support.

We discovered that the service did not have a functioning quality assurance system. We discovered problems in a number of areas that had not been picked up by the manager. We learned that, for example, the manager needed further training on some aspects of employment law.

The provider was in the home on a regular basis but both he and the manager had not made plans to improve the service until regulators had pointed out deficiencies to them. We were concerned that issues around fire and food safety, the environment and behavioural planning had not been picked up by them.

The people we spoke to in Howard Court told us they were happy with their care. Comments included,

“I like living here as my family are able to visit”.

The staff are very good, really nice girls”.

We found that people’s care and support needs had been assessed and kept under review to help ensure people received the care they needed. We saw that people had access to health care professionals. The people we spoke to told us they received the help they needed when they needed it and that staff did encourage them to remain as independent as possible.

There were procedures in place for medicines handling and storage. Medicines records were, on the whole, up to date but the checks were not always up to date. We have made reference to this in the body of the report.

Records with regards to the maintenance of equipment were in place and were available for inspection.

During our visit we spoke with people living there, visitors and staff about the way in which care was provided and how involved residents and their families were in any decisions made. We also asked people about the attitude of the staff and if they were happy with the way they were treated.

People told us,

"I came here for a rest and decided to stay and I am very happy".

"I go for a walk into town every day".

"Some of us are going out this afternoon to a local school".

Visitors told us,

"The staff are fantastic and very helpful"

"The staff are wonderful and have made my relative very welcome".

People we spoke to told us they enjoyed living in Howard Court. Comments included,

‘I enjoy it here and the staff look after me well’

I like my room and can choose where to sit in the day’

‘I can eat in my room if I want to’

‘The staff are very kind and we can have a joke together’.

This was an unannounced inspection that took place on 27th and 30th of July 2015.

The home was last inspected on 6th and 7th October 2014. .At this inspection in October 2014 we rated the service as inadequate. The home was in breach of the following regulations of the Health and Social Care Act (HAS) 2008 (Regulated Activities) Regulations 2010.

Regulation 9 Care and Welfare of people who use services.

Regulation 10 Assessing and monitoring the quality of service provided

Regualtion12 Cleanliness and infection control.

Regulation 13 Management of medicines.

Regulation 14 Meeting nutritional needs.

Regulation 23 Supporting staff.

Regulation 11 Safeguarding people who use services from abuse

Regulation 21 Requirements relating to workers.

The above regulations have now been replaced with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found that the home was no longer in breach of any of the above regulations and met all of the 2014 Regulations.

Howard Court Care Home provides accommodation for up to 28 older people some of whom may be living with dementia.

The home is owned by Howard Court Care Home Ltd and is situated in the centre of Brampton, a market town approximately eight miles from Carlisle, and close to all amenities and public transport.

Accommodation is in mainly single rooms. Some rooms have ensuite toilet facilities. There are some rooms which can be shared by two people. The home has a large lounge diner on the ground floor. Upstairs there is a small lounge and connected dining area. The 1st floor is accessed by both a passenger lift and a stair lift.

The provider is also registered to provide personal care to people in their own homes. We did not conduct an inspection of this activity on this visit.

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 and associated Regulations about how the service is run.

We judged the home to be safe because the provider had ensured that all staff had been trained to identify and report any potential harm or abuse of vulnerable adults. We had evidence to show that senior staff understood how to report, and where appropriate, manage any issues related to possible abuse.

Risk assessments related to the environment and the delivery of care were up to date. Accidents and incidents were managed correctly.

The home employed sufficient staff to meet the needs of the eighteen people who lived in the home. This was because the provider had increased staffing numbers and looked at how staff were deployed.

New staff were recruited properly and disciplinary action taken if any member of the team was not fulfilling their job role.

We found that the provider had significantly improved the way medicines were managed. People received their medicines at the times they needed them and in a safe way.

Infection control had improved. The staff team had been suitably trained and had access to personal protective equipment. The home was clean and orderly.

All of the staff had received induction training no matter how long they had worked in the home. This had been followed up by training in all the core subjects the provider felt the team needed. Some staff had received further specialist training in subjects such as dementia care and end of life care.

We checked on staff supervision and appraisal and we found that the registered manager had now updated all of these records. Staff told us they now received good levels of both formal and informal supervision which had helped them to develop. Staff said that communication at all levels had improved.

We saw that good nutritional planning was in place. People who had been quite seriously underweight at our last visit had put on weight and were no longer undernourished. One person who was overweight had been helped to lose weight. People we spoke to were happy with the food provided.

We saw evidence to show that the team had support from the local G.Ps and the community nurses. We also saw that specialists like dieticians and mental health workers came into the home. The dementia care team held regular clinics in the home so that people living with dementia would get the right levels of support.

The home’s environment had improved with new furniture purchased and suitable redecoration and refurbishment was continuing.

We judged that the care staff approach was much more individualised. Staff had been training in person centred thinking and we saw a much more focussed approach on the needs and strengths of people in the home. People told us the staff team were caring, respectful and supported them to retain as much dignity and independence as possible.

Assessment and care planning had developed. We now saw care planning that identified need and gave staff guidance. Care plans were reviewed, analysed and reassessed so that the most appropriate approach was followed.

Activities and entertainments were happening in the home and future planning in place for increasing activities that would meet the needs and preferences of the people living at Howard Court..

We saw that the registered manager and the provider were much more confident about how the home was running. The provider had employed a consultant who had helped them deal with quality issues and had provided training for the staff. The provider had taken appropriate action with staff who found it difficult to change their practice.

We found that the records relating to the way the service operated were up to date and detailed. Systems in the home now met the needs of the people who lived there, supported staff and ensured the environment met people’s needs. This was because the homes own quality monitoring system was being followed and any problems dealt with swiftly.