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 presence in the service and staff felt supported. However; the manager demonstrated a lack of knowledge about the systems in place at the service and had no awareness of the concerns we found. Staff were not clear on the visions and values of the provider organisation.
Safe recruitment processes were in place and had been followed to ensure that staff were suitable for the role they had been appointed to prior to commencing work.
People received support from health and medical professionals when required. Medicines were managed safely.
People's privacy was promoted throughout their care and staff sought people’s consent before any care was provided.
Complaints were consistently managed, recorded and responded to.
The service was clean and tidy. Relevant infection control procedures were observed. Cleaning schedules and routines in place demonstrated the improved practices at the service in maintaining a safe, clean environment.
During this inspection we found multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.
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.