This inspection took place on 23, 25 and 29 May 2018 and day one was unannounced. It was prompted in part by the receipt of a number of concerns from health care professionals about the alleged poor management of pressure care and a number of incidents involving people using the service, including the death of one person. We did not look at the circumstances of this incident during this inspection as it is subject to a separate police investigation, but we did look at associated risks.

Hurst 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.

Hurst Hall accommodates 50 people. The home is a purpose built single storey building. There are 50 single occupancy bedrooms, 33 of which have an en-suite toilet. There were two separate communal lounge/dining areas, a conservatory and a paved garden/courtyard area. The home has a small car park. At the time of our visit there were 41 people living at Hurst Hall.

We last inspected Hurst Hall on 16 and 17 August 2016 when we rated the home as requires improvement overall and for each of the five key questions other than caring, which was rated good. At the last inspection we identified multiple breaches of four of the regulations of the Health and Social Care Act (Regulated Activities) Regulations 2014. These were in relation to the safe management of medicines, safety of the premises, seeking consent, person centred care and good governance. We issued a warning notice for good governance which identified a timeframe that the service needed to be compliant with the regulation by. We also asked the provider to complete an action plan to show what they would do and by when to improve.

At this inspection we found satisfactory action had been completed to ensure the safe management of medicines, safety of the premises, seeking consent and person centred care. However, we identified a continued breach of regulation 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014, relating to a lack of maintaining accurate, complete and contemporaneous records. You can see what action we told the provider to take at the back of the full version of this inspection report.

There was a registered manager in place, although, at the time of this inspection the person was on extended leave. 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 service was being managed by an experienced manager brought in to manage the service during the registered manager’s absence. Throughout the report we have used the term ‘acting manager’ for the current manager in charge of the service.

We found issues in relation to care and treatment records, such as positional change records not being consistently maintained. We also found concerns relating to pre-admission assessment documentation not being fully completed with all required details. Lack of clear recording and appropriate completion of documentation could put the person receiving support at risk of inappropriate care and treatment being provided.

Medicines were found to be safely managed. We saw that records of medicines administration were accurately completed and all medicines were stored safely.

Staffing levels were sufficient at the time of the inspection to meet the needs of people who were cared for and supported by the service.

We found there was a safe and robust system of staff recruitment in place. All pre-employment checks were completed before an offer of employment was made.

We observed positive interactions between staff and people living at the

This inspection took place on 16 and 17 August 2016 and was unannounced.

Hurst Hall is a residential care home registered to provide care and accommodation for up to 50 people. The home is situated in Ashton Under-Lyne, Greater Manchester. The home is a purpose built single storey building. There are 50 single occupancy bedrooms, 33 of which have an en-suite toilet. There were two separate communal lounge/dining areas, a conservatory and a paved garden/ courtyard area. The home has a small car park. At the time of our visit there were 49 people living at Hurst Hall.

We last inspected Hurst Hall on 12 and 13 October 2015 when we rated the home as requires improvement overall and for each of the five key questions other than caring, which was rated as good. At the last inspection we identified multiple breaches of the regulations, which related to the safe management of medicines, assessing and mitigating risk, infection control, cleanliness, assessing preferences and monitoring the safety of the service.

We found improvements had been made in some areas; however we also identified some on-going breaches of the regulations. At this inspection we identified multiple breaches of four of the regulations of the Health and Social Care Act (Regulated Activities) Regulations 2014. These were in relation to the safe management of medicines, safety of the premises, seeking consent, person centred care and monitoring and improving the quality and safety of the service. You can see what action we told the provider to take at the back of the full version of this inspection report. We are currently considering our options in relation to enforcement in relation to some of the breaches identified. We will update the section at the end of this report once any action has concluded.

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. The registered manager was also the registered manager at another location run by the provider and they had registered to manage Hurst Hall whilst a new permanent manager was being recruited. A new permanent manager was in post at the time of our inspection and was in the process of registering with CQC.

We found evidence the provider and acting manager were in the process of making improvements to the service. For instance, we saw a new format of care plans had been introduced, there was an on-going refurbishment of the environment, and the acting manager was taking steps to make the environment more ‘dementia friendly’. However, these changes had not been completed at the time of our inspection.

We found issues in relation to the safety of the environment. Locks on doors to areas containing electrical equipment did not function properly and would allow people to access these areas. The provider took action to fix the locks, but had not identified this concern before we had raised it. We also found there were on-going issues in relation to the heating system at the home. This meant the heating could not be fully turned off on the day of the inspection, which was a warm day. The room of one person who was cared for in bed was very warm and the provider did not have adequate systems in place to monitor the temperature of the environment despite the known issues with the heating system. There was no evidence of actual harm to this person and the provider took action to reduce the room temperature. However, the provider had failed to identify and act on this risk until this was highlighted by the inspection team.

Staff were able to demonstrate a reasonable understanding in relation the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS), and

The people who we spoke to who used the service were happy with Hurst Hall and had no complaints. Comments included “I like it a lot, everybody is very caring.” And “I can make my own decisions and get up when I want.” Another person said “I am quite satisfied, the staff are very considerate.”

Relatives of people who used the service were also satisfied. One relative said “Staff have been excellent here, they are very friendly.” And another relative said “I have been made to feel welcome.”

We found that the people who used the service are treated with dignity and respect and are able to make choices about their lives. One relative commented “Preferences and choices were taken into consideration.”

The care that people received was planned and reviewed and changed according to need.

The home was clean and well maintained.

Staff received the appropriate training to do their job successfully and felt well supported by senior staff. One member of staff “we get a lot of training, such as fire , manual handling and dignity.”

The home has systems in place to make it a safe environment for people to live in.

We gathered evidence of people's experience of living in the home by talking to them, talking to their relatives and observing people going about their daily lives. We spent time observing staff interacting and engaging with people. We also looked at the complaints log and care plan records.

We saw that people in the home were supported by a fully trained staff team who had a good knowledge of individual care needs. We saw that staff used care plan records as a working tool to support them in providing care and support to people in a way that matched their individual needs and preferences.

We found that care plans were regularly updated to reflect any changes in care need requirements and that where possible people and their relatives were informed and involved in the process.

The service had good systems in place to manage the medication in the home and to ensure that people received their medication in a safe way.

There was a robust complaints system in place that encouraged and supported people to express their views and opinions.

People we spoke with told us that staff were kind and helpful and that they were satisfied with the care and support they received.

Some of the people using this service were able to express their views about the care and support they were receiving at Hurst Hall. Comments included:

"It's fine living here. They (the staff) are very good and look after us well."

"I would like to go home really, but I can't. The staff are really lovely and all you do is open your mouth and ask and they do their best for you."

People told us that routines in the home were flexible and that they were supported to be involved in the day to day activities in the home.

People told us that they had no complaints but said if they did they would have no hesitation in speaking to staff or management about them.

All the people we spoke with told us they were comfortable in their environment and thought the home was clean and well maintained.

This inspection took place on 12 and 13 October 2015. Our visit on the 12 was unannounced.

Prior to this inspection, we received a copy of a coroner’s Regulation 28: Report to prevent future death following an inquest into the death of a person living at Hurst Hall. The service was previously inspected on 12 November 2013, when no breaches of legal requirements were found.

When we visited the service there was a registered manager in place. 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.

Hurst Hall is registered to provide care and accommodation for up to 50 people. The home is situated in Ashton Under-Lyne Greater Manchester. The home is a purpose built single storey building. There are 50 single occupancy bedrooms, 33 of which have an en suite toilet, there were two separate communal and dining areas that supported people spending time together. There was a paved garden/ courtyard to the rear of the property and a small car park.

At the time of our visit 40 people were living at Hurst Hall.

We found thirteen breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to staffing, management of medicines, supporting workers, care and welfare of people who used the service and the systems for assessing the quality of the service provided. You can see what action we told the provider to take at the back of the full version of the report.

We found a person’s care plan was not written in a person centred way which might place the person of receiving unsafe or inappropriate care. This was in breach of regulation 9(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 the care and treatment of service users must be appropriate, meet their needs and reflect their preferences.

There was a policy in place to support the safe administration of medicines. However, we found prescribed skin creams that should have been stored safely had been left on the window ledge of an unlocked bathroom and we saw that staff did not have full view of the unlocked drugs trolley at all times. This meant that people were at risk of harm because medicines were not managed safely. This was in breach of Regulation 12 12(2)(g) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 the proper and safe management of medicines.

The temperature of the medicine room exceeded the recommended 25 degrees Celsius room temperature as recommended in the NICE quality standardon managing medicines in care homesMarch 2015, and this might compromise the stability of the medicines stored in the room which might put people at risk of harm. This was in breach of Regulation 12 12(2) (g) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 the proper and safe management of medicines.

The National Institute for Health and Care Excellence (NICE) provides national guidance and advice to improve health and social care. It develops guidance, standards and information on high quality health and social care.

We saw two staff handling soiled continence pads without using appropriate protective equipment such as disposable gloves and aprons which would help to prevent cross infection. This was in breach of Regulation 12(2)(h) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 detecting and controlling the spread of, infections, including those that are health care associated.

Risk assessments about the health, safety and welfare of people using the service needed adjustments so that instructions for staff were clear to make sure people could receive personalised care that was responsive to their needs. This was in breach of Regulation 12(2)(a) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

We found an unlocked bathroom with a bath that contained water mixed with a sterilising detergent being used to clean commode buckets and people’s support aids. There was no signage on the bathroom door to identify the room type or prevent unauthorised people from entering the bathroom. This meant that people were at risk of harm if they entered the bathroom unsupervised. This was in breach of Regulation 12(2)(b) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 doing all that is reasonably practicable to mitigate any such risks.

Records of accidents and incidents that had occurred to people living at the home between 4 July 2015 and 3 August 2015 we noted that an outcome to each incident had not been recorded. This meant that people were at risk of harm because the manager could not identify any themes and the action necessary to reduce the risk of incidents reoccurring. Regulation 12(2)(a) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

A portable appliance test (PAT) had not been carried out on a large number of small electrical appliances in use around the home. This meant that people were at risk of harm if they used the unchecked appliances because it was not known if they were safe to use. This was in breach of Regulation 12(2)(b) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 doing all that is reasonably practicable to mitigate any such risks.

There was an overall stale smell throughout the home and we saw that furniture such as dining chairs, mattresses, armchairs and soft furnishings required deep cleaning to make sure they were suitable for their intended purpose. Some parts of the home lacked investment and required redecorating, repair or renewal. Particular parts of the home such as tiled walls in shared bathrooms and the main kitchen required high level cleaning to make sure that people live in an environment that is clean, free from odours that are offensive and unpleasant. This was in breach of Regulation 15(1)(a) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Premises and equipment must be kept clean and cleaning dine in line with current legislation and guidance. On the second inspection day we noted some areas of the home and furnishings in the small lounge dining room had been cleaned overnight. This cleaning helped to improve the malodour noted on the first day of the inspection.

When we walked around the home we found that none of the radiators temperature could be individually controlled. We recommend that the service considers that radiator temperature gauges are accessible at all times to people to create a satisfactory environment temperature to suit people’s preferences

There were a number of quality assurance systems in place at the home but these were not used effectively and were not sufficiently robust to identify the risks and the shortfalls we found during the inspection. For example an accident and incidents file contained a summary of incidents that had occurred in August 2015 however no outcomes to the incidents had been recorded during that period. This meant that people were at risk of receiving care in an unsafe way because the manager did not make sure the service delivery and the health and safety of people was not compromised. This was in breach of regulation 17(1) the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Doing all that is reasonably practicable to mitigate any such risk. Systems and processes must be established and operated effectively to ensure compliance with the regulations

The provider had set out and followed an action plan and protocols for staff to follow in relation to them being clear about how to arrange for the attendance of a general practitioner (GP) for a resident who was not fully registered with a local GP on moving into the home.

All staff at Hurst Hall had received training in the appropriate use of calling for emergency and urgent care (999) or non-emergency care (111), raising awareness of their duty to request for the GP to look at another resident when visiting other resident’s in the home and understanding the legal requirement for prompt reporting of matters of concern to the Care Quality Commission.

We observed staff verbal “hand-overs” at each shift change was effective to fall in line with the care workers every day routines and systems.

People told us that they felt safe in the home and staff knew how to protect people from the risk of abuse. Where they were able to tell us about their experiences people who used the service told us staff were kind and caring. Positive feedback was also given by relatives about the attitude and approach of staff.

People told us they would feel able to raise any concerns they might have with staff or the registered manager and were confident they would be listened to. A log of complaints was maintained by the service and we saw evidence that action had been taken to investigate any concerns raised.

We saw there were good relationships between individual staff and people who used the service and we saw that care was provided with kindness. Staff employed at the home had received training to help them provide care to people to meet their needs and were clear about how to respect people’s privacy and dignity, and understood how to put this into practice.