This inspection visit took place on 24 October 2018 and was unannounced.

At the last comprehensive inspection in June 2017 we found three breaches of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We rated the service overall as requires improvement. The areas of improvement identified were in relation to providing a safe environment, supporting decision making and consent, and leadership and governance.

At this inspection we found that improvements had been made to help ensure a safe environment however; other improvements had not been made and there were additional areas that did not meet the standards. We found breaches of regulations in relation to providing safe care, mental capacity and decision making, involving people in their care, staff training and leadership and governance of the service.

Howe Dell Manor 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.

Howe Dell Manor is a converted manor house in Hatfield, Hertfordshire that accommodates up to 19 people living with mental health conditions. At the time of this inspection there were 18 people living at the service.

The service had a manager who was in the process of applying to be registered. 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.

Systems in place to protect people from harm were ineffective. Incidents had occurred at the service which were not recorded or reported appropriately to ensure the safety of people. Staff had received training on safeguarding procedures but not all staff were clear about identifying where people were at risk.

Risks to service users’ health and well-being were not appropriately identified, assessed and managed. Risks assessments in place did not offer robust guidance to staff on how individual risks to people could be minimised. Assessments had not consistently been updated or reviewed following changes in people’s care needs.

Staff had not received sufficient training to meet the individual needs of people. Staff had been supported with regular supervision and appraisals, however staff supervision did not seek to develop staff skills further.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible; the policies and systems in the service did not support this practice. The requirements of the Mental Capacity Act 2005 and associated Deprivation of Liberty Safeguards were not met.

People told us that they had a variety of food and were complimentary about the meals that were provided at the service. However, on the day of our inspection, special diets were not catered for by the agency chef on duty.

People did not consistently receive caring support. Many people described staff as caring but others had experienced negative encounters. Language used in care records did not always promote people’s dignity.

Care plans took account of individual needs but lacked detail with regards to people's preferences, choices and individuality. The plans were not reflective of people’s needs and did not always include clear instructions for staff on how best to support people.

Quality assurance processes were not robust, effective or used to improve the service being provided. Audits had failed to identify the concerns found during our inspection. The provider and manager had not acted upon previous inspection feedback with a view to evaluate and improve practice and ensure compliance with the regulations.

The manager was a visible presenc

Howe Dell Manor provides accommodation and personal care for up to 19 people with mental health needs. On the day of the inspection, there were 16 people living in the service with another person having recently been admitted to hospital.

We carried out an unannounced comprehensive inspection of this service on 29 January 2016 and rated it ‘Good’.

The service does not have a registered manager. A new manager has been appointed but is not yet registered. 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.

An appropriate level of cleanliness was not maintained throughout the service. We found that people’s bedrooms and a number of communal areas were unclean and the methods used by domestic staff when completing cleaning tasks were ineffective. The courtyard and communal gardens were poorly maintained.

People's needs had been assessed and care plans took account of their individual needs but lacked detail with regards to their preferences, choices and individuality. Individual risk assessments were in place however these lacked guidance for staff on how individual risks to people could be minimised. Care plans and risk assessments had been regularly reviewed by senior staff however it was not evident how people, and their relatives if appropriate, had been involved in the process and their views included in the planning of care.

A consistent number of staff on duty was maintained however people and staff raised concerns regarding the staffing level at the service. A formal staffing level assessment had not been completed by the manager and a recent change to the shift pattern worked by nursing members of staff was reported to have had a negative impact on the staff team.

People’s capacity to make and understand the implication of decisions about their care were not consistently assessed or documented within their care records. There was no evidence that, where people lacked capacity to make or understand decisions, those made on their behalf had been made in accordance with the Mental Capacity Act 2005 and associated Deprivation of Liberty Safeguards. However, people’s consent was gained before any care was provided.

People told us there had been a recent deterioration in the quality of the meals provided at the service. People were supported to make choices in relation to their food and drink however inconsistent menu choices were offered due to the absence of regular kitchen staff.

A limited range of activities were provided at the service however we observed staff engage people in social conversations outside of times where there was a high demand for their assistance.

There was a complaints procedure and policy in place. People knew who to raise concerns with however the complaints book for people to record their concerns in was not confidential.

Quality assurance processes were not robust and there was a lack of evidence of any recent audits to check the quality of the services provided. There was no evidence as to how the completed audits were used to drive improvements in the service. The arrangements for the management and storage of personal documents for people living at the service was not robust.

People told us they felt safe. Staff understood their responsibilities with regards to safeguarding people and they had received effective training. Referrals to the local authority safeguarding team had been made appropriately when concerns were raised.

Staff felt that they were trained and had the skills and knowledge to provide the care and support required by people. New members of staff received an induction.

Safe recruitment processes were in place and had been followed to ensure that staff were suitable for the role they

This inspection took place on 29 January 2016 and was unannounced. The home provides accommodation and personal care for up to 19 people with mental health needs. On the day of the inspection, there were 18 people living in the home.

The service 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.

People were safe and there were systems in place to safeguard them from the possible risk of harm. However, risk assessments did not give clear guidance for staff on how to manage and minimise the risk. The provider had not followed fire safety advice to ensure that each person had an individual evacuation plan. Medicine administration records were not always completed fully to show that people’s medicines had been managed safely.

The service followed safe recruitment procedures and there were sufficient numbers of suitable staff to keep people safe and meet their needs.

People were supported by staff who were trained, skilled and knowledgeable on how to meet their individual needs. Staff received supervision and support, and were competent in their roles.

Staff were aware of how to support people who lacked the mental capacity to make decisions for themselves and had received training in Mental Capacity Act (2005) and the associated Deprivation of Liberty Safeguards. People’s nutritional needs were met and they were supported to have enough to eat and drink. They were also supported to access other health and social care services when required.

People were treated with respect and their privacy and dignity was promoted. People were involved in decisions about the care and support they received.

People had their care needs assessed, reviewed and delivered in a way that mattered to them. They were supported to pursue their social interests and hobbies and to participate in activities provided at the home. There was an effective complaints procedure in place.

There were systems in place to seek the views of people, their relatives and other stakeholders. Regular checks and audits relating to the quality of service delivery were carried out. There were effective systems in place to monitor the quality of the service.

The people we spoke with were complimentary of the care and support they received from the staff. One person said "I love it here. Staff are very good. The food is good. There are plenty of activities and I have no complaints." Another person said "I have been here for over three years and everything is fine. I have nothing to suggest."

During this inspection we found that the provider was meeting the standards we had inspected. People's needs were assessed and met appropriately. There was a policy and procedures in place to report any allegations of abuse. There was a system in place for the safe administration and management of medicines. People were cared for and supported by a team of trained and qualified staff. There was a system for assessing and monitoring the quality of service.

The Care Quality Commission received information of concern regarding this service. We decided to visit Howe Dell Manor to complete a responsive review of compliance. The registered manager reported that there were 15 people who use the service in the building. Following a tour of home with a member of staff we confirmed that there were 14 people which included one person who was on home leave.

During our visit to Howe Dell Manor, on 26 March 2013, we observed that there was some building and maintenance work being carried out. The provider told us the annexe was being converted into flats. There was a strong odour that could be associated with damp in the ground floor corridor. We were told that this was because a new concrete floor was being laid in the kitchen. However, other parts of the home showed visible signs of dampness. The area of the home where the work was being carried out was very cold.

The operations manager told us there had been a number of issues at the home recently and these were being addressed. A new manager had been appointed and had been in post since January 2013. The management team were working through some of the issues that needed to be addressed in the immediate, medium and long term.

Two people who lived at Howe Dell Manor said they were happy but other people made negative comments about certain aspects of the home, including making reference to a particular member of staff who they found difficult to get on with.

During our visit to Howe Dell Manor, on 16 May 2012, people were positive about the service provided. People told us there was a calm atmosphere and space to get away from each other if needed. People said that they liked the meals they were being served. People were able to confirm that staff provided support and involved them in decisions about their care and treatment. One person told us their key worker was ‘excellent’. Another person, with experience of other placements, told us that Howe Dell Manor was ‘better than many other places’. We observed positive interaction between people using the service and the staff present. People were happy to approach the manager or staff to discuss issues as they occurred and got a positive response.

The eleven people we met during our visits to the service, on 18 and 19 October 2011, were generally positive about the service they are receiving at Howe Dell Manor. People said it was ‘okay’ and they were getting on ‘alright’. One person told us it was the ‘best place they had ever lived’.

People were able to tell us that they got on well with the staff and felt safe living here. They said they didn’t have problems with the other people who live here. One person told us about an occasion when they felt a member of staff had been abrupt in their approach to them. Another person told us staff always make sure they are comfortable.

People told us about the leisure, educational and work based opportunities available to them. One person told us about the positive role staff had played in setting their course up and supporting them to continue.

One person told us about plans to live more independently and the preparations they were making by managing their finances, being responsible for cleaning their room, looking after their laundry and eventually learning to cook.

People told us that they liked their rooms, which they had been able to add their personal possessions to. They said there was plenty of space at Howe Dell Manor to get away from other people and to be alone if they wished.

People told us they liked the meals provided and can make snacks and cups of tea for themselves in one of the kitchenettes provided.

People told us they had keys to their rooms and had asked for the door code at a recent resident meeting which is under consideration by the management team.