Holgate House

Holgate House is a residential care home providing personal care to people with mental health needs or learning disability. The service can support up to 30 people. At the time of inspection 23 people were using the service.

People’s experience of using this service and what we found

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. 'Right support, right care, right culture' is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Right Support

Risks to people were not always effectively managed. This included individualised risks and risks in relation to the environment.

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 and in their best interests; the policies and systems in the service did not support this practice. Work was required to ensure decisions were made on individualised basis rather than ‘house decisions,’ to ensure people received person centred care. Capacity assessments and best interest decisions had not always been recorded.

Right Care

People had good relationships with the staff. People were supported to access health care appointments.

The service had enough appropriately skilled staff to meet people's needs and keep them safe.

Right Culture

Staff felt supported by the registered manager and that it was good place to work.

The provider's quality monitoring processes were not robust and had not always identified concerns and improvements in the service identified during the inspection.

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

Rating at last inspection

The last rating for this service was good (published 23 December 2019)

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We undertook a focused inspection to review the key questions of safe and well-led only. We inspected and found there was a concern with Mental Capacity Act, so we widened the inspection to include the key questions effective.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe, effective and well-led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Holgate House on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to risk management and governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

We have made recommendations in relation to medicines and infection prevention and control.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Holgate House is a care home providing personal care for up to 30 people who have a mental health support need, or a learning disability and/or autism. They support older and younger people. At the time of our inspection 20 people lived at the service.

People’s experience of using this service

We received positive views from people about the support provided. Care and support was tailored to each person's needs and preferences. People were fully involved in developing and updating their planned care.

People and staff told us the registered manager was approachable. All feedback was used to make continuous improvements to the service. The provider had systems in place to safeguard people from abuse and staff demonstrated an awareness of safety and how to minimise risks.

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 received their medicines on time and their health was well managed.

People were supported to take positive risks and be independent. Staff knew people’s likes and dislikes well and were effective at managing risk.

People were supported with their communication needs and staff demonstrated effective skills in communication. Recruitment checks were in place to ensure staff were suitable to work at the service. Staff were skilled to meet the needs of people.

The outcomes for people using the service reflected the principles and values of Registering the Right Support by promoting choice and control, independence and inclusion. People's support focused on them having as many opportunities as possible for them to gain new skills and become more independent.

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

Rating at last inspection

The last rating for this service was good (published 23 June 2017).

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

At this inspection we found that governance had improved, quality audits had taken place to identify any shortfalls and action had been taken to address the shortfalls. Recording in care plans and risk assessments was consistent, including records of people’s nutritional needs.

The home is registered to provide accommodation and care for up to 30 older people and younger adults with varying needs that include learning disabilities, autistic spectrum disorder and / or mental health. On the day of the inspection there were 19 people living at the home. The home is situated close to the centre of York. the main house has two floors; there is no passenger lift so people who are accommodated on the first or second floors have to be able to manage the stairs. There are also some ground floor flats to the rear of the premises.

The registered provider is required to have a registered manager in post and on the day of the inspection there was no manager registered with the Care Quality Commission (CQC). 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. A new manager had been appointed on 13 March 2017 and they had commenced the registration process with CQC.

Care plans included information to guide staff on how to meet people’s assessed care and support needs. There were some minor anomalies in care plans but this had not affected people’s well-being or the support people had received.

People were protected from the risk of harm or abuse because there were effective systems in place to manage any safeguarding concerns. Staff were trained in safeguarding adults from abuse and understood their responsibilities in respect of protecting people from the risk of harm.

There was evidence that the registered provider was working within the principles of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). No-one living at the home had a DoLS authorisation in place but the registered manager had submitted applications that were being considered by the local authority.

There were recruitment and selection policies in place and these had been followed to ensure that only people considered suitable to work with vulnerable people had been employed. On the day of the inspection we saw that there were sufficient numbers of staff employed to meet people's individual needs.

Staff told us that they were well supported by senior managers. They also told us they received the training they needed to carry out their roles effectively, including training on the administration of medicines. This was confirmed in the records we saw.

We checked medication systems and saw that medicines were stored, recorded and administered safely.

People who lived at the home told us that staff were caring and that staff respected people's privacy and dignity. We saw that there were positive relationships between staff and people who lived at the home, and that staff had a good understanding of people's individual care and support needs.

Activities were provided and people were encouraged to take part, although some people told us they preferred the trips out to the activities provided within the home.

We saw that people's nutritional needs had been assessed and individual food and drink requirements were met. People told us that they were happy with the food provided and we observed that there was a choice at mealtimes. There were facilities for people to make themselves a drink throughout the day.

The premises were undergoing an extensive refurbishment programme. We noticed unpleasant odours in two people’s bedrooms but we were assured that these bedrooms were next to be refurbished. The areas of the home that had been refurbished had been completed to a high standard.

There were systems in place to seek feedback from people who lived at the home, relatives and staff. People told us they were confident their complaints and concerns would be listened to. Any complaints made to the home had been thoroughly investigated and appropriate action had been taken to make any required improvements.

Five of the identified breaches, which included Regulation 11(Need for consent), Regulation 14 (Meeting nutritional and hydration needs), Regulation 15 (Premises and equipment), Regulation 18 (Staffing) and regulation 17 (Good governance) were assessed as having a low service impact and we dealt with these by issuing a requirement for improvement notice to the registered provider. The registered provider sent us an action plan that contained information on how they intended to meet those regulations and achieve compliance, which was checked during this inspection and we found this action has been completed for these breaches with the exception of Regulation 17 (Good governance) where we identified a continued breach in regulation.

The four remaining breaches were assessed as having a moderate service impact and we dealt with these by issuing the registered provider with a written Warning Notice for improvement for each breach. The breaches we dealt with in this way were Regulation 9 (Person centred care), Regulation 10 (Dignity and respect), Regulation 12 (Safe care and treatment) and Regulation 13 (Safeguarding service users from abuse and improper treatment). A planned focused inspection was completed on the 20 and 21 June 2016 and at that time we found improvements had been implemented and the warning notices were met.

Holgate House provides accommodation for up to 30 older people and younger adults with varying needs that include care and support for learning disabilities, autistic spectrum disorder and/or mental health. At the time of our inspection there were 18 people receiving a service.

Holgate House did not have a registered manager. The previous registered manager submitted an application to cancel their registration to manage all regulated activities and have their registration removed on 15 January 2016. 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. The inspection was facilitated by the commercial director. The commercial director told us they had successfully recruited to the post of manager and once the required pre-employment information checks had been completed for the individual they would be submitting an application for the manager to be registered with the Care Quality Commission. .

Despite the improvements and implementation of systems and processes that helped to identify manage and mitigate risks to people, we found that improvements were not consistent or sustained. Where avoidable risks had been identified in people’s care plans this information was not always up to date, or reflective of people’s current needs. Where reviews had been completed, the information was not available in people’s care plans as a point of reference for care workers and other health professionals involved with peoples care and support. Guidance was not robust to help people remain safe from avoidable harm. This meant systems and processes to assess, prevent and raise awareness of risk to provide a basis for appropriate support by staff were found to require further improvement.

Where the registered provider had concerns about people’s capacity or where a Deprivation of Liberty Safeguards (DoLS) had expired, referrals had been submitted to the local authority for further assessment under the Mental Capacity Act 2005. However, information on mental capacity assessments was not available in all care plans for people and there was not always information in people’s care plans that ensured staff supported the person where a need for a Deprivation of Liberty Safeguarding had been submitted.

Information was documented in people’s care plans to record their choices and to help them maintain a healthy nutritional diet. The registered provider had installed small kitchen areas where people could cook snacks and prepare hot and cold drinks. Care workers supported people to eat at meal times but discussions found that they were not always aware of people’s dietary needs. Care plans contained up to date information on people dietary requirements and support with nutrition. Information in the dining room file also provided a reference point for people’s diet and nutritional needs but this information was out of date. The registered provider had implemented some improvements and people told us they were happy with mealtime arrangements.

We observed an improvement in the way some people presented themselves. However, we observed two people were wearing ill-fitting clothes that were not always clean, did not have clean fingernails and appeared in undignified state. The registered provider was aware of our concerns and ensured people’s choice and preferences were respected. However, care workers seemed unsure of how to address the concerns we raised and they told us they thought people’s personal care had improved. We found and our observations confirmed there was a lack of comprehensive records to guide staff and despite multiagency involvement in people’s personal care, people were not always supported to live in a dignified manner, which meant that their personal care needs may not be fully supported.

The registered provider was in the process of reviewing and updating people’s care records. Care workers had received training in care planning and told us that file reviews were ‘a work in progress’. We found that information was not consistently updated. It was not clear when information about people had been recorded in daily diary notes, which meant people might have received inappropriate care that did not meet their needs putting them and staff at risk.

Care plans included information regarding people’s wishes and preferences however, we found this was not consistent and updated information was not available in care plans for everybody who lived in the home.

Despite the introduction of additional staff to support some people with daily activities, we found staff were not always aware of people’s preferences and did not always support them with their chosen activity.

Improvement measures had been implemented by the registered provider that evaluated service performance and the environment of the home. Audits were in place and along with action plans and review meetings progress was evaluated in a timely manner. However, due to the improvements still required and the omissions and inconsistencies of people’s records we found these quality assurance measures were ineffective in ensuring people received safe care and support that met with their individual needs, preferences and choices and kept them safe from avoidable harm wherever possible.

The service had been without a registered manager since 15 January 2016. However, there was a management structure in place and recruitment of an employee for the role was in process. The commercial director acknowledged the recruitment of a manager would bring further stability to the home and would be an asset in driving forward the work required to ensure people’s care and support met their individual needs. Despite the measures implemented, that we saw had led to some improvements at the home, we found the above concerns meant appropriate systems processes and management oversight was not always effective in identifying, assessing, prioritising or monitoring and mitigating the risks to the health and safety and welfare of service users and others.

Because of the above concerns that we evidenced during this inspection, we found the registered provider was in continued breach of Regulation 17 (Good governance). You can see what action we told the provider to take at the back of the full version of the report.

Five of the identified breaches included Regulation 11(Need for consent), Regulation 14 (Meeting nutritional and hydration needs), Regulation 15 (Premises and equipment), Regulation 17 (Good governance) and Regulation 18 (Staffing). These breaches were assessed as having a low service impact and we dealt with these by issuing a requirement for improvement notice to the registered provider. The registered provider sent us an action plan that contained information on how they intended to meet with those regulations and compliance with these regulations will be inspected at our next comprehensive inspection.

The four remaining breaches were assessed as having a moderate service impact and we dealt with these by issuing the registered provider with a written Warning Notice for improvement for each breach. The breaches we dealt with in this way were Regulation 9 (Person centred care), Regulation 10 (Dignity and respect), Regulation 12 (Safe care and treatment) and Regulation 13 (Safeguarding service users from abuse and improper treatment). This inspection was planned to focus on whether improvements had been made by the registered provider to rectify the four breaches dealt with by way of written Warning Notices only.

This report covers our findings in relation to the Warning Notices. You can read the report from our last comprehensive inspection by selecting the 'All information’ and searching for Holgate House on our website at www.cqc.org.uk.

Holgate House is a care home service without nursing. The service provides accommodation for up to 30 older people and younger adults with varying needs that include care and support for learning disabilities, autistic spectrum disorder and/or mental health. At the time of our inspection there were 19 people receiving a service. Holgate House is located in the historic city of York with good public transport links. Off road parking is available at the rear of the building for visitors.

Holgate House did not have a registered manager. The registered manager submitted an application to cancel their registration to manage all regulated activities and have their registration removed on 15 January 2016. 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. At the time of our inspection, we were supported by the nominated individual and the commercial director who were running the service.

We saw that all care workers had now received up to date safeguarding training. The registered provider had a policy and procedure in place for safeguarding vulnerable adults. Care workers were aware of types of abuse to look out for and knew how to report their concerns. People told us they felt safe. This meant people were being protected from abuse and improper treatment. We saw these changes resulted in the registered provider meeting the breach of regulation, previously identified in the Warning Notice for Regulation 13 Safeguarding service users from abuse and improper treatment, under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Systems and processes for risk assessments, prevention of risk and awareness of risk were found to have been updated. Risk assessments had been completed for people and we saw these were documented and reviewed in people’s care plans. We saw care plans included information to help people evacuate the service in the case of an emergency. Fire checks were robust and care workers had received appropriate training in fire awareness. Security around the service had been improved and we saw appropriate risk assessments documented for the service and the environment. We saw these changes resulted in the registered provider meeting the breaches of Regulations, previously identified in the Warning Notices for Regulation 12 Safe care and treatment, under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

During this inspection, we found that all care workers who administered medicines had completed refresher medicines training. Medication audits were carried out with resulting actions documented. We observed medicines were handled appropriately by care workers. People received their medicine at the correct time of day and this was signed by the two care workers who administered the medicines. Medicines including controlled drugs were safely and correctly stored. Other health professionals told us that the management of medications had improved and we saw this was the case from the reduction in notifications for medication errors we had received since our last inspection. We saw these changes resulted in the registered provider meeting the breaches of Regulations, previously identified in the Warning Notices for Regulation 12 Safe care and treatment, under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. However, the medication policy did not reflect current practice at the service. The registered provider agreed to review and update this policy. This was part of an on-going breach of Regulation 17 (2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We are monitoring the breach of Regulation 17 separately and this will be reviewed as part of our follow up inspection.

All care workers had completed training in ‘Management of Actual or Potential Aggression (MAPA)’. This meant care workers had received training at a suitable level to make sure any control, restraint or restrictive practices were only used when necessary. Care plans had been reviewed and where appropriate updated with an individual behaviour management support plan and risk assessments. Where the registered provider had concerns about an individual’s capacity to make informed decisions they had included referrals to other health professionals and care workers had received training in and had a basic understanding of the requirements of the Mental Capacity Act 2005 (MCA). We saw these changes resulted in the registered provider meeting the breaches of Regulations, previously identified in the Warning Notices for Regulation 13 Safeguarding service users from abuse and improper treatment under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We observed people were supported with their personal care. Care plans we reviewed contained personal hygiene risk assessments and monitoring records. People were addressed and spoken with in line with their preferences by care workers who understood their needs. This meant people were treated with dignity and respect by care workers and others around the home. We saw these changes resulted in the registered provider meeting the breaches of Regulations, previously identified in the Warning Notices for Regulation 10 Dignity and Respect, under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Care plans contained information about people's health needs and contact details of health and social care professionals involved in supporting the individual. This meant there were systems in place to ensure that people were supported to access healthcare services where necessary.

People were involved in the planning of their support and care. We saw that where the person was able to sign their consent to the planned care and support this had been included. This meant the information was reflective of people’s current needs. We saw these changes resulted in the registered provider meeting the breach of Regulations, previously identified in the Warning Notice for Regulation 9 Person centred care, under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People had completed and signed to agree to a ‘Smokers agreement’. Care plans included a smoking risk assessment and information on how to support the individual. We observed people were no longer smoking in communal areas and we saw care plans contained signed smoking agreements and documented discussions regarding enforcement. This meant the registered provider had appropriate measures in place to minimise the risks associated with people smoking in the home and in their rooms and we saw this work was on-going. We saw these changes resulted in the registered provider meeting the breach of Regulation, previously identified in the Warning Notices for Regulation 13 Safeguarding service users from abuse and improper treatment, under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Care plans we looked at centred on the person and included details on how to support people with daily living. People had a documented named key worker and a list of people involved in their care. We observed care workers spending one-to-one time with people and a range of activities that included days out, trips and holidays had been implemented and were supported. This meant that the registered provider had taken steps to ensure sufficient care workers were available to meet people’s individual needs and that these were documented and reviewed with people. People were not left in avoidable isolation and were receiving person centred care and support in line with their preferences. We saw these changes resulted in the registered provider meeting the breaches of Regulations, previously identified in the Warning Notices for Regulation 9 Person-centred care under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We saw duri

Holgate House is a care home service without nursing. The service provides accommodation for up to 30 older people and younger adults with varying needs that include care and support for learning disabilities, autistic spectrum disorder and/or mental health. At the time of our inspection there were 19 people receiving a service. Holgate House is located in the historic city of York with good public transport links. Off road parking is available at the rear of the building for visitors.

Holgate House did not have a registered manager. The registered manager submitted an application to cancel their registration to manage all regulated activities and have their registration removed on 15 January 2016. 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 provided us with a mixed response about the support and care they received. It was clear from talking with people and looking at care plans that care was not person centred and we saw that people who used the service, their relatives and friends did not contribute to people’s care planning. This was a breach of Regulation 9: Person centred care under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People told us they felt safe, but they told us they had concerns around their safety and the staff who cared for them. Where people had raised concerns with the registered provider regarding their safety, these had not been addressed.

Staff had not all received up to date training in safeguarding adults from abuse and some staff when asked, were unable to identify all the types of abuse they should look out for when caring for and supporting people. This meant that people were not protected from abuse and improper treatment. This was a breach of Regulation 13: Safeguarding service users from abuse and improper treatment.

Care plans had not been updated and staff that supported people did not have access to up to date information on people’s current needs. Although some of the risk assessments we looked at were up to date, we saw these were inconsistent with their care plans and other assessments and that resulting actions had not been carried forward. There was no evidence of how people were being supported or how their risks were being monitored to keep them and others safe.

The above issues meant people were not receiving care and support in a safe way appropriate to their needs. This was a breach of Regulation 12: Safe care and treatment under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The service had a recruitment policy. However, low staffing levels were identified as a serious concern by staff, people and others. The registered provider told us that they did not use a staffing dependency tool and we saw there was insufficient staff, who lacked the appropriate knowledge and skills to meet people’s changing needs and to keep them safe. This was a breach of Regulation 18: Staffing under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We checked the recruitment records for nine staff. We saw that staff had completed an application form that included an equal opportunities statement. Files contained two references and checks had been made with the Disclosure and Barring Service (DBS).

We saw that although the registered provider had a training matrix in place and had implemented a training programme for staff, not all training for staff was up to date. Where gaps in training had been identified there were not always scheduled dates to determine when this training would be completed. This meant that not all staff had received sufficient training to carry out their roles effectively. We saw staff supervisions were inconsistent, some staff had not received supervision at all and others told us they were informal and did not have documented outcomes recorded. This was a breach of Regulation 18: Staffing under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We saw a medication policy and administration procedure was in place along with a policy on self-administration for people. We asked staff and they told us they understood the policy. We saw staff had received some training in safe management of medication, but competency assessments were outstanding for some staff. We observed a medication round and looked at people’s medication administration records. We saw staff did not always follow the policy and procedure and that staff were not competent in the medication process resulting in errors of administration and recording. This meant that care and treatment was not provided in a safe way for people. This was a breach of Regulation 12: Safe care and treatment under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The registered provider had a contract in place for two cleaners however, we saw areas throughout the home that were not clean including communal areas, peoples rooms and service areas. There was a strong smell of cigarettes that was at times overpowering despite the home having a ‘no smoking policy’. This was a breach of Regulation 15: Premises and equipment under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People complained about the laundry facility and we saw a backlog of people’s dirty clothes mixed with clean clothes and a lack of staff and equipment to undertake the task. We observed people wearing dirty clothes and who had unwashed hair. People told us that they had not received appropriate support with their personal care. We observed staff and others did not always knock and wait for a response from people before entering their rooms. This was a breach of Regulation 10: Dignity and respect of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Some staff had received training in and had a basic understanding of the requirements of the Mental Capacity Act 2005. We looked at people’s care files and we saw where applications for deprivation of liberty safeguards were required these were inconsistent and in some instances had not been completed. People told us they did not receive appropriate guidance, which included information on how to access advocacy services to ensure they understood their legal rights. This meant the registered provider did not adhere to the Mental Capacity Act 2005, which includes the duty to consult others such as carers, families and/or advocates where appropriate. This meant people might have received care and support without consent, which was a breach of Regulation 11: Need for consent.

We saw that people were residing at the home and receiving services under section 117 of the Mental Health Act 1983. We saw no evidence that staff had received training in the Mental Health Act 1983. Staff did not demonstrate an understanding of the act which meant they did not have the required skills and competency to provide appropriate care and support to meet people’s needs. This meant people were not protected from abuse or improper treatment under the Mental Capacity Act 2005. This was a breach of Regulation 13: Safeguarding service users from abuse and improper treatment under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We saw the kitchen in the home had no hand soap or hand towels and that daily operational records and checks for the kitchen were incomplete. This meant that the registered provider did not maintain equipment to ensure standards of hygiene were appropriate for people and others. This was a breach of Regulation 15: Premises and equipment under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We saw that people had been involved in discussions regarding their food and meal times. However, the resulting changes failed to recognise the individual dietary requirements and specific meal times required by individual people. We saw there was a lack of choice in food available at midday due to the lack of staff available to provide the choices on the menu.

People’s nutritional charts including food and fluid charts were not up to date and lacked consistency. The registered provider told us this was in part due to staff not correctly filling the charts in or not updating them on a regular basis.

The above issues meant people’s nutritional needs were not assessed, managed and documented appropriately. This was a breach of Regulation 14: Meeting nutritional and hydration needs under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People’s dignity and privacy was not always respected in the home. Other people entered people’s rooms without announcement, consent or due consideration. This was a breach of Regulation 10: Dignity and respect under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We saw people did not receive personalised care that was responsive to their needs. People did not always receive care which was person centred, met their needs and reflected their personal preferences. This was a breach of Regulation 9: Person-centred care under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Staff, people and others told us there were no scheduled activities for people to undertake or join in with. We observed some people remained in their rooms all day and other people walked aimlessly around the communal areas or sat isolated without staff intervention for long periods. We