About the service: Howlish Hall is a residential care home that was providing personal care to 27 people aged 65 and over at the time of the inspection. The service can accommodate up to 40 people.

People’s experience of using this service: During our inspection we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 relating to ensuring the safe care of people, staffing and effective governance arrangements.

The service had recently used agency staff but had not reassured themselves that the agency staff were suitable to work in the home. Pre-employment checks were carried out on permanent staff before they began working in the service. Staff were supported through induction and training, although they did not receive supervision in line with the provider’s policy.

Further work was required in the service to ensure people were safe. This included making emergency pull cords accessible and ensuring seating for people in the lounge was appropriate.

Checks on the service to monitor its effectiveness and quality failed to identify the deficits we found during the inspection. Some improvements such as fire safety and the updating of policies had taken place. However, this is the third successive CQC report when the service has required improvement.

Staff told us they felt supported by the registered manager who was working on shifts as a senior carer. This reduced their capacity to manage the service and implement improvements.

Improvements were required in people’s meal time experiences. The approach of staff in supporting people to eat was variable and not always dignified.

Staff were trained and assessed as competent to administer people’s medicines. Oral medicines were safely administered. There were gaps in the records held by the service on people’s topical medicines.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. People were given choices and their decisions were respected. However, we found the documentation used to assess people’s capacity was not in line with Department of Health guidance.

A new electronic system was being introduced by the provider to record people's care needs. Information had yet to be transferred and updated from the paper records to the electronic records. Further work was required to ensure these records provided clear guidance to staff on how to meet people’s care needs.

Accidents and incidents were documented by staff and reviews of the information was carried out by the registered manager who checked to see if they could have been avoided.

The service employed an activities coordinator who ran daily activities. Staff supported the activities by helping people join in the games.

Risks of cross infection were reduced as regular cleaning took place. Staff used gloves and aprons to avoid the spread of any infections.

People were protected by staff who were trained in safeguarding. Staff described to us scenarios where they had made alerts to the local authority when they had concerns about people’s welfare.

People were complimentary about the care they received from staff. They told us staff protected their privacy and promoted their independence.

People who used the service and their relatives were invited to participate in the service through quarterly meetings. Relatives had contributed raffle prizes to the service. Their views had been sought using a questionnaire. They had suggested improvements were required in the décor and the gardens.

Staff had asked people about their end of life wishes. These were documented in people’s files together with decisions on whether to be resuscitated.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection: The overall rating was Requires Improvement (Published 20 December 2018.)

Why we inspected: Following the last inspection the provider sent us an a

This inspection took place on 13 and 16 November 2018 and was unannounced. The provider knew we would be returning for a second day but not when.

Howlish Hall 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 service is registered for 40 people and at the time of inspection there were 31 people living at the service.

A registered manager was in post at the time of the inspection visit, although they were absent on both days. They were registered with the Care Quality Commission in July 2013. 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.

The last inspection of the service was carried out in November 2017 and was rated requires improvement. We found that the service was not meeting all the requirements of Health and Social Care Act 2008 and associated Regulations. We found concerns relating to their emergency policies and procedures not always being followed, records were not effective at monitoring and recording staff training and the provider’s systems for assessing, monitoring and improving standards at the service were ineffective. Following this inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions to at least good.

At this inspection we found that the provider had made some improvements however we found further improvements were required to become fully compliant with the Fundamental Standards of Quality and Safety. This is the second time the service has been rated requires improvement.

We found concerns with the safe administration of medicines, fire drills did not support staff to keep people safe and the personal emergency evacuation plans (PEEPs) were not in place for two people and were in place for one person who had left the service. The purpose of a PEEP is to provide staff and emergency workers with the necessary information to evacuate people who cannot safely get themselves out of a building unaided during an emergency. Following the inspection the fire service completed an inspection of the service and provided an urgent action plan for the provider to follow.

Audits were taking place; however, they were not robust enough to highlight the issues we found during our visit. Records, were difficult to locate and once found in no order. It was highlighted at the last inspection that the provider did not complete any quality assurance checks at the service and the registered manager did not record their daily walk around. We asked to see them at this inspection and we were told there were no records kept of daily walk arounds and the provider does not complete any records to evidence checks of the service.

Risks assessments arising from people’s health and support needs needed to include more information to minimise the risk, be more person centred and to be updated or new risk assessment put in place when people’s needs changed.

Risks arising from the premises were not always assessed. Doors leading to stairwells were not locked on opening but were locked on closing. Meaning if a person opened the door on the bottom floor they could climb upstairs but be greeted by a locked door and have to go back down, a person opening the door on the top floor would not be able to get back in once the door shut and would have to navigate the stairs.

People who lived at the service were safeguarded from abuse. People told us that they felt safe at the service and that they trusted staff. Staff were booked in for refresher training in the safeguarding of vulnerabl

This inspection took place on 1 November 2017 was unannounced. This meant the registered provider and staff did not know we would be visiting. This service was last inspected in November 2015 and was rated Good.

Howlish Hall Nursing and Residential Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service accommodates 40 people across two floors. At the time of our inspection 38 people were using the service.

The service had 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.

The provider had policies and procedures in place to support people in emergency situations. However, these were not always consistently applied or carried out. Staff received the training they needed to support people effectively but that training records were not effective at monitoring and recording staff training. The provider’s systems for assessing monitoring and improving standards at the service were ineffective.

Risks arising out of people’s support needs were assessed and plans put in place to reduce the chances of them occurring. The premises were clean and tidy and staff understood the principles of infection control. People’s medicines were managed safely. Policies and procedures were in place to safeguard people from abuse. The provider’s recruitment process minimised the risk of unsuitable staff being employed. Staff also gave us mixed feedback on staffing levels.

We made a recommendation that the registered manager uses a recognised staffing tool to monitor and plan staffing levels.

Staff were supported through regular supervisions and appraisals. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this. People were supported to maintain a healthy diet and to access external professionals involved in their healthcare. The premises had been adapted to meet the needs of people living there.

People spoke positively about the care they received at Howlish Hall, and described staff as kind and caring. Relatives also spoke positively about the caring nature of staff and they support they delivered to people. Staff had close but professional relationships with people living at the service. People and their relatives told us staff helped them to maintain their independence but were always available to provide support when needed. Throughout the inspection we saw lots of examples of kind and caring support and of warm and friendly interactions between people and staff. People were supported to access advocacy services where needed.

People received personalised care that was responsive to their needs and preferences. Care plans were regularly reviewed to ensure they reflected people’s current support needs and preferences. People told us they were supported to take part in activities they enjoyed. Policies and procedures were in place to investigate and respond to complaints. Policies and procedures were in place to arrange end of life care where appropriate.

Staff spoke positively about the culture and values of the service. One member of staff said, “It’s a beautiful home. People and their relatives also spoke positively about the ethos of the service. Staff said they were supported in their roles by the registered manager. Feedback was sought from people, relatives and staff and was acted on. The service had links with local organisations that were used to enhance the wellbeing of people using the

In this report the name of the registered manager appears who was not in post and not managing this location at the time of this inspection. Their name appears because they were still a registered manager on our register at that time.

People told us they were happy with the care they received and staff checked they were in agreement with it. We saw staff consulted people before they provided care and support.

We found people's needs were assessed and care was planned in line with their needs. One person said, "They really look after me, they discuss how I want things all the time, it's brilliant."

Records were available to show that the manager monitored the administration records of medication. This meant that people's medicines were checked regularly by the manager to see that staff were administering, ordering and disposing of them properly.

Appropriate checks were undertaken before staff began work.

There was an effective complaints system available and a clear way of identifying complaints. We found that comments and complaints people made were documented and responded to appropriately.

People who used the service were happy with the care they received. One person told us "They (the care staff ) are lovely." Another person told us "They're angels." One of the staff we spoke with told us "I love working here."

We found people were generally happy with their surroundings although there were limited activities and some people said they were bored. Some people were concerned that if they wanted to participate in activities they had to go to the day centre within the home.

We saw staff at the home were respectful and courteous to people who lived there. Staff encouraged people to be independent and were knowledgeable about people's requirements.

We saw the home was clean and had a regular cleaning schedule in place.

We saw people's records were detailed and held relevant information, like visits from dentists, chiropodists and opticians.

Several service users spoke with us during this visit. Their comments were very positive about the service they received. One person said, “We’re very well looked after. All the nurses are lovely.”

Another said, “I love it here.”

Another person said, “I receive very good support, nothing is too much for them. I am respected here and they listen to what I have to say.”

One person said, “I would know what to do if I wanted to make a complaint.”

Another person said, “I have nothing to complain about, this is a wonderful place.”

One person said, “I love my bedroom because there are wonderful views of the gardens and countryside. I think the facilities here are excellent.”

Another person said, “It is always lovely and clean, I have no complaints at all.”

One person said, “I think they all do a very good job, I receive good support from them.”

Another person said, “All the nurses here are wonderful, they always have time for me, they work hard and do a very good job.”

A relative said, “I have no concerns at all, this place is exceptional.”

A visitor told us, “it’s fantastic - I can’t praise them enough for what they have done for my mother she has made a remarkable recovery since coming here. The care here is exceptional.”

A relative said, “It’s a very good service. I don’t know what we would do without it. I visit daily to see my wife and I have lunch and tea with her everyday. The staff team are a great support to my wife and me.”

The inspection took place on 9, 10 and 11 September 2015 and was unannounced. This meant the registered provider or staff did not know about our inspection visit.

We previously inspected Howlish Hall Nursing and Residential Home on 8 August 2013, at which time the service was compliant with all regulatory standards.

Howlish Hall Nursing and Residential Home is a home in Bishop Auckland providing accommodation and nursing care for up to 40 older people who require personal care. 34 people were living in the home at the time of our inspection, 15 of whom were living with dementia.

The service had a registered manager in place. 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.

We began the inspection on the evening of 9 September 2015 in response to concerns raised with the CQC about levels of staffing overnight. We found that there were sufficient numbers of staff on duty in order to meet the needs of people using the service. All staff were trained or had training scheduled in core areas such as safeguarding, moving and handling, infection control and first aid. The service had a dedicated member of staff who organised training. We found that staff had an adequate knowledge of people’s preferences, needs, likes and dislikes.

We observed discreet and thoughtful interactions during our inspection and saw evidence in recorded documentation of the promotion of people’s right to dignified care. Relatives and external stakeholders told us that people were treated well and mostly agreed that the service was welcoming and effective.

There were effective pre-employment checks of staff in place and effective staff supervision and appraisal processes.

The service was mostly clean throughout and had acted on the majority of recommendations by the infection control team, although we did observe one requirement had not been acted on. During our inspection we also found a room used for storage and a sluice room left unlocked, which presented hazards to people using the service; these were rectified immediately.

Person-centred care plans were in place for all people using the service and the registered provider sought consent from people for the care provided. We saw that the registered provider was in the process of revising care planning and handover processes. We saw that there had been a number of failures to record aspects of care given, such as hourly positional checks and fluid intake records. The registered provider was able to show us that they had identified failings in the handover system used and had started the process of reviewing how all care plans and handovers were recorded.

The registered provider ensured relatives and healthcare professionals were involved in ensuring people’s medical, personal, social and nutritional needs were met.

The service had a robust set of policies and procedures to deal with a range of eventualities. Most people using the service we spoke with, relatives, staff and external professionals were complimentary about the management and ethos of the service.

The CQC monitors the operation of the Deprivation of Liberty Safeguards [DoLS], which applies to care homes. DoLS are part of the Mental Capacity Act 2005. They aim to make sure that people in care homes, hospitals and supported living are looked after in a way that does not inappropriately restrict their freedom. The registered manager was knowledgeable on the subject of DoLS and had provided appropriate paperwork to the local authority to deprive people of their liberty, where it was in their best interests.