This inspection took place on 7 November 2018 and was announced. At our last inspection in August 2017 we found the provider in breach of regulations relating to safeguarding, safe care and treatment, staff training and governance. We took enforcement action and issued requirement notices for safeguarding and staffing and served a warning notice for safe care and treatment. 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 to at least Good. The provider sent us an action plan detailing how they were going to address these concerns. At this inspection we found the provider had made the necessary improvements.

Kestrel House is a ‘care home’. People in care homes received 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. Kestrel House accommodates up to 19 people, with mental health needs, in one adapted building. At the time of our inspection there were 19 people living at the home. Each person has their own room with shared communal facilities, including bathroom, living and dining area and communal garden. There is an office on the ground floor and arrangements in place for staff to sleep in.

There was a registered manager in post. 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 protected from the risk of abuse because systems were in place to protect them. Risks to people were assessed and people supported to stay safe and their freedom respected. There were sufficient numbers of staff on duty to meet people’s needs. Since our last inspection in August 2017 the provider had increased staffing levels. Medicines were now managed and stored safely. People were protected from the risk of infection because the service followed infection control practices and staff were provided with the necessary personal protective equipment. Systems were in place to learn and make improvements to the service following an accident or incident.

People’s needs were assessed and care and treatment delivered in line with people’s plan of care.

Staff were supported to ensure they had the necessary skills, knowledge and experience to effectively provide care and support. People were encouraged to eat and drink enough to maintain a balanced diet. The service worked within the legal requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. Staff understood the need to ask people for their consent before providing care and treatment. People had access to other healthcare professionals to ensure their healthcare needs were met.

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 practice.

People were treated with dignity and respect and their privacy maintained. People’s independence was promoted.

The service had a complaints procedure in place and we found that complaints were investigated and where possible resolved to the satisfaction of the complainant.

Staff told us the registered manager was approachable and listened to concerns. The service had improved the way they carried out quality assurance and monitoring of the service.

We made two recommendations relating to staff recruitment and staff training.

This inspection took place on 30 August 2017 and was unannounced. We first inspected the service in October 2015 when the service was rated as inadequate and placed into special measures. We asked the provider to take action to make improvements in relation to consent, safeguarding people from abuse, meeting nutritional needs, safe care and treatment, person-centred care, good governance and notification of other incidents.

At our last focused inspection in May 2016 the service was rated overall as requires improvement. Although the provider had made improvements since our last comprehensive inspection in October 2015, we found mental capacity assessments were incorrectly completed and better understanding of the Mental Capacity Act 2005 and associated guidance was required for staff. We made a recommendation to this effect.

At this inspection we found that staff were not able to explain what the MCA meant in relation to the people they worked with and some had not received training in this area.

Kestrel House provides care and support for up to 19 people with mental health needs. At the time of our inspection 18 people were living at the home.

The registered manager was away on leave on the day of our visit. 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.

Staff felt supported by the registered manager and received supervision and yearly appraisal.

Safeguarding procedures were in place. However, some staff did not have an understanding of what constituted abuse.

Infection control practices were not always followed. We found food incorrectly stored and opened food unlabelled in the fridge. Areas of the kitchen were in need of cleaning.

Medicines were not managed safely and there were gaps in medicines administration records, including missed medicines and out of stock medicines.

Staff were subjected to the necessary checks before starting work. However, we found gaps in staff training in areas such as the Mental Capacity Act 2005 (MCA) and safeguarding.

Risk assessments were detailed in places and provided staff with information on how to mitigate the risks identified. However some gaps were noted relating to specific health risks, such as diabetes.

Systems to monitor the quality of the service were not effective and did not ensure that the quality of the service was maintained. The registered manager failed to have oversight of the service and did not conduct regular audits to ensure the service operated effectively. We found care records for people living at the home had a number of gaps.

In spite of a number of incidents where staff safety had been compromised, the risks to staff who worked alone had not been assessed.

People's nutritional needs were met and people participated in activities. People felt they were given choice and staff treated them with dignity and respect.

People and staff felt at busier times that the service would benefit from having additional staff. We made a recommendation regarding staffing levels.

We found four breaches of the regulations relating to safeguarding, safe care and treatment, consent, staff training and governance.

Full information about CQC’s regulatory response to any concerns found during inspections is added to the back of the full version of the reports after any representations and appeals have been concluded.

The inspection took place on the 24 and 31 May 2016 and was unannounced on the first day.

The service had a number of breaches of the regulations at our last inspection on the 14 and 15 October 2015.

The breaches related to safe management of medicines, seeking consent, safeguarding, meeting nutritional needs, person centred care, notifications of Deprivations of Liberty Safeguards (DoLS) and good governance.

Kestrel House is registered to provide care for up to 19 adults with mental health needs. At the time of our inspection there were 17 people 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 service had made some improvements since our last inspection and are no longer rated as inadequate in any key question and therefore no longer in special measures. However there were still improvements to be made around staff understanding of mental capacity.

People’s medicines were now administered and recorded in a safe way. Records showed people were receiving their medicines when they needed them, there were no gaps on the medicine administration records and any reasons for not giving people their medicines were recorded. Medicines were now audited to check daily stock balances.

Risk assessments were more detailed and guidance was now given on how to manage and support people to keep them safe. Risk assessments were current and were updated after incidents. However the service needed to ensure that falls risk assessments were updated. People's care plans were more personalised with goals they wanted to achieve and descriptions on what success would look like. The service listed people’s preferred name and after the inspection they sent us evidence that they had completed people’s life histories.

People told us they felt safe and relatives said they had no concerns about the safety of their family member. Records showed that safeguarding and accidents and incidents were notified to the CQC and to the local authority as required.

The service was meeting the requirements of the Deprivation of Liberty Safeguards. Records showed that five people were deprived of their liberty lawfully and in their best interests and the service had followed the correct procedure and informed the CQC. Mental capacity assessments had been completed but in two cases there were errors on the form and they lacked detail. More staff understanding of mental capacity was needed and policies in this area needed to be provided to staff. We have made a recommendation in this area.

At our last inspection people who needed support with nutrition had not been identified and were not receiving adequate support in this area. During our recent inspection people who required special diets were supported to eat well and this was recorded in their care plan.

People and their relatives said staff were caring and we observed staff be kind towards people. The service had implemented personal histories about people and people were more involved in their care planning.

The registered manager showed us photographs of improvements made to people’s bedrooms after people had asked for them. This made their bedrooms more personalised and people had said how happy it made them.

The service had introduced new auditing systems to monitor the quality of the service and staff had commented that there was more auditing taking place and they thought it was good. Staff and residents met regularly to discuss the service. The registered manager recorded and documented all of their audits and some of these included Records were in the process of being updated however quality assurance systems did not always identify missing informat

We inspected Kestrel House on 14 & 16 October 2015. This was an unannounced inspection. At our last inspection on 7 May 2013 the service was not compliant with Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. During our last inspection the provider was not meeting the legal requirement in relation to care and welfare. Previous to September 2015 the service was incorrectly stated to be registered as Brian Holiday when it was in fact Shanti Healthcare Limited.

Kestrel House is registered to provide care for up to 19 adults with mental health needs. At the time of inspection there were 17 people living at the home.

There was a registered manager at the service 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.

People told us they felt safe however records showed that safeguarding incidents were not always reported on to the relevant authorities. Risk assessments were not robust and did not provide sufficient detail to mitigate risks identified. There were inconsistencies in how risks were managed and this put people at risk of harm.

Care was not always planned and provided in response to people’s needs. Care plans were out of date and not tailored to the needs of each person, leaving them at risk of unsafe or inappropriate care.

Medicines were not effectively managed and did not have a clear audit trail so people were at risk of harm from receiving the wrong medication. We saw that medicines had not been appropriately signed for on the Medicine Administration Record (MAR) and that stocks of medicines could not be accounted for. Some people had not received their medicines as prescribed.

The provider was not meeting the requirements in relation to the Deprivation of Liberty Safeguards (DoLS) and had not followed the appropriate procedures to act in people’s best interests.

People were not always provided with appropriate food and nutrition. People requiring special diets for weight loss were not always identified within their care plans and there was no recorded meal planning to ensure they received the right balanced diet.

Care files did not contain life histories or information about the interests and aspirations of people using the service. People had mixed views being involved with their care plan. All the care files we saw had similar phrases and information about the care to be provided, with limited personal information. People’s care files had three monthly reviews however the service did not monitor and evaluate all goals set up in people’s care plans.

There were no effective systems for monitoring and auditing the quality of care and the service.

The registered manager had not notified CQC of any safeguarding incidents or other statutory notifications as required.

Staff received training and one to one supervision. People were able to make choices about most aspects of their daily lives. People were provided with a choice of food and drink. People had access to health care professionals.

People and their relatives told us they liked the staff. Staff had a good understanding of how to promote people’s dignity.

We found seven breaches of Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the Care Quality Commission (Registration) Regulations 2009. You can see what action we told the provider to take at the back of the full version of this report.

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.