Archived: Harmony House

Harmony House is a care home, which provides accommodation, personal and nursing care for up to 57 older people, some of whom are living with complex health conditions or dementia. The home has two floors, with numerous communal lounges, and a dining area. People had their own en-suite bedrooms. There is a communal garden area. At the time of our inspection there were 42 people living at Harmony House.

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

People told us they were happy living at Harmony House and described the home as having a happy atmosphere with things to do. Staff demonstrated a kind and caring approach toward people and gave support when needed.

Most risks were well managed, and staff had risk management plans to refer to telling them how to reduce risks of harm or injury to people. However, some risks had not been identified by the provider or registered manager and this posed risks of harm to people.

Staff were trained and offered opportunities to develop their skills and knowledge. However, the provider and registered manager had not ensured staff always had the guidance they needed to use all equipment safely, such as specialist beds.

People had all their prescribed tablet medicines available to them, but staff did not always ensure people had their prescribed topical medicines. Staff did not always follow manufacturer’s guidance in how medicines should be given through the skin.

People had choices about drinks and what they ate for their main meals. However, appropriate nutritional snacks were not always made available to meet people’s dietary requirements.

The home was well-maintained and good cleanliness reduced risks of cross infection.

Staff understood the importance of giving people choices. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People’s needs were assessed, and information was used to form plans of care. Work was ongoing to further personalise people’s care plans.

There were enough staff on shift to meet people’s needs. Improvement had been made to ensure staff consistently worked on one floor of the home so people were cared for and supported by the same staff. Staff were recruited in a safe way.

There were systems in place for people and relatives to give their feedback on the service. The provider’s complaints policy was displayed, and concerns were acted on.

Improvements had been made to staff morale and they felt supported by the registered manager.

There were processes to audit the quality and safety of the service. Some issues had been identified as requiring improvements and were acted on. However, some audits, checks and oversight of staff were not robust enough and had not identified where improvements were needed. Intended improvements were not always sustained by staff or embedded in the culture of the home.

Following our inspection feedback, the regional manager and registered manager took some immediate actions to make improvements. This included increased managerial oversight to ensure people were offered appropriate and nutritional snacks.

We reported that the registered provider was in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were:

Regulation 17 Regulated Activities Regulations 2014 – Good governance

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

Rating at the last inspection

The last rating for this service was Requires Improvement (published 4 January 2019). The service has been repeatedly rated Requires Improvement since 2015.

Why we inspected

This was a planned inspection based on the rating of the last inspection.

Follow up

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

Harmony House is operated by Larchwood Care Homes (North) Limited; a large provider of care homes. Harmony House provides nursing care and accommodation for up to 57 people. The majority of people who live at the home are people living with physical frailty due to complex health conditions and / or older age. Some people are living with dementia. The home offers end of life care to people. The home provides one temporary ‘discharge to assess’ bed for a person who has come from hospital for further care or assessment before going back to their own home or finding a suitable care home. At the time of our visit there were 36 people living in the home.

People in care homes receive accommodation and 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.

There was a newly appointed manager in post. They had begun the process of applying to become registered with us for this service. 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.

At our last inspection in September 2017 we rated the service as Requires Improvement. This was because in five of the key areas we checked, we found improvements were required. Following our September 2017 inspection, the regional manager has updated us weekly on their progress. At this inspection, we found some improvements had been made in the five key areas we checked. However, further improvements were still required. The overall rating continues to be Requires Improvement.

People were supported by trained staff, who overall, followed the provider’s policies and training given to them. People felt staff had the appropriate levels of skill, experience and support to meet their care and support needs. Individual risk management plans were in place for staff to follow and staff knew what action to take in the event of an emergency.

Staff understood their responsibilities to protect people from the risks of abuse and told us they would share any concerns they had following the provider’s safeguarding policies. The provider’s regional manager and home manager understood and followed their legal responsibilities when safeguarding concerns were identified to them by staff or through checks made. The provider checked staff’s suitability to deliver care and support during the recruitment process.

People were supported to eat a balanced diet and encouraged to eat and drink enough to maintain their wellbeing. Overall, staff supported people to access support from external healthcare professionals to maintain and promote their health.

People received their medicines as prescribed, but staff had not always followed the manufacturer’s guidance in relation to medicines given through skin patches. Overall, medicines were stored safely, though staff did not consistently ensure medicines were locked in the trolley when it was left unattended. Overall, people were protected from the risks of cross infection and the home was clean and tidy.

Staff had received training in the Mental Capacity Act 2005 and worked within the principles of the Act. Managers understood their responsibilities under the Act and when ‘best interests’ meetings should take place. Staff supported people with kindness and in a caring way to meet their physical care and support needs. People’s privacy and dignity was respected.

People had individual plans of care which provided staff with the information they needed. Staffing levels meant staff focused on people's physical care needs and did not always have time to meet people's emotional needs. There were very limited activities offered to people, however, an activity worker had been recruited. There was ‘work in progress’ to offer one to one and group activities to support people’s individual needs.

Staff were happy in their job role and felt supported by the regional manager and home manager through meetings. People and their relatives had no current complaints about the service. Concerns and complaints raised were investigated by the provider.

The provider’s regional manager and home manager checked the quality of the service to make sure people’s needs were met. There was recognition that improvements made needed to be embedded into the service. Audits had identified the need for further improvements to be made to the service and these were ‘work in progress.’ The provider, regional manager and home manager understood their regulatory responsibilities and with other organisations and healthcare professionals to ensure positive outcomes for people who lived at the home.

Further information is in the detailed findings below.

Harmony House provides accommodation, nursing and personal care and support for up to 57 people living with physical frailty due to complex health conditions and / or older age. At the time of the inspection 35 people lived at the home. The home is split over two floors; each with a communal lounge and dining area.

The home is required to have 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 and associated Regulations about how the service is run. Since our last inspection there had been some changes in the management of the home. A new home manager had started work there during April 2017 and was in the process of becoming registered with us.

After our inspection in June 2016 we served the provider and previous registered manager a ‘warning notice’ because regulations had not been met and the service was rated as ‘inadequate’. In January 2017 we inspected again. During this inspection visit we found improvements had been made and the home was rated as ‘requires improvement’. However, there continued to be a breach of the regulations in relation to the governance of the home, and a breach of the regulation in relation to the safe care and treatment of people. The provider agreed voluntarily to restrict admissions to the home until improvements were made and send us improvement action plans each month, which they did.

At this inspection, we found sufficient improvements had been made to meet the requirements of the warning notice and regulation relating to governance of the home. The rating remains ‘requires improvement’ with no breaches of the regulations.

The home manager and a new regional manager, who had also started during April 2017, told us they had implemented improvements and had further improvements planned for. The manager told us a change in culture at the home was work in progress and their passion was to create a home that offered a good service to people. The manager felt supported by the regional manager who visited and spent time at the home every week. Staff felt supported and were complimentary about the management changes.

There were however some provider led changes that staff felt impacted on them. The manager and regional manager had agreed to escalate some of these concerns to senior management.

Overall, people and their relatives felt improvements were being made. People knew who the manager was and relatives described them as approachable. Systems were in place to gain feedback from people and plans were in place to provide opportunities for people, relatives and staff to give feedback during August 2017.

Improvements had been made, overall, to the safe care and treatment of people. Most risks of potential harm to people were identified. However, where risks had been assessed, actions to minimise those risks were not always followed by staff. Staff felt they knew what to do in the event of emergencies. However, the provider’s fire risk assessment recommendation had not been incorporated into planned fire drills.

Safe systems were in place for recruiting staff. People had their prescribed medicines available to them and were supported with these by nurses.

Staff were trained and nurses given opportunities to refresh their clinical skills. Staff worked on both floors of the home and opportunities for effective communication between nurses, such as shift handover was not always detailed. Staff worked within the principles of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards on a day to day basis. However, care records around people’s mental capacity was inconsistent.

People’s hydration and nutritional needs were met, although people’s weight was not always monitored as planned for. People were supported to maintain their wellbeing and were referred to health professionals when needed.

People described staff as kind and caring, however staff member’s attention to people’s personal grooming and dignity was not always consistent.

People had individual care plans in place. There were opportunities for relatives to be involved in how care was given through reviews, which the manager had plans to improve on. Activities were offered to people, though, overall, people felt further improvement was needed to meet their individual needs.

People and their relatives knew how to make a complaint if needed. Audit systems and processes to monitor the quality and safety of the service had improved since our last visit, and these were used to identify where improvement was needed.

Harmony House provides accommodation, nursing and personal care and support for up to 57 people living with physical frailty due to older age and complex health conditions. At the time of the inspection 37 people lived at the home. The home has two floors; on the days of our visit, the ground floor offered two residential care beds and 15 nursing beds. People on the first floor all required nursing care.

The home is required to have 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 and associated Regulations about how the service is run. At the time of this inspection the home had a registered manager who had been in post since March 2015 and registered with us since August 2015.

When we inspected the home in March 2015 we found a breach in the governance of the home and the legal requirements and regulations associated with the Health and Social Care Act 2008 were not being met. A requirement notice was served on the provider to tell us what action they would take to make improvements. At our last inspection in June 2016, we found improvements had not been made. We identified breaches in the management of medicines and the safe care and treatment of people. A continued breach in the governance of the home resulted in enforcement action being taken and we served a warning notice on the provider and the registered manager. The home was placed in ‘special measures.’ The special measures framework is designed to ensure a timely and coordinated response where we judge the standard of care to be inadequate. Services in special measures are inspected again within six months following the publication of the inspection report.

At this inspection we looked to see if the provider and registered manager had responded to make the required improvements in the standard of care to meet the regulations. Whilst we found that sufficient improvements had been made to remove the service from ‘special measures,’ we found further improvements were required. The requirements of the warning notice served had not been fully complied with. Further improvements in how the senior managers assured themselves that they were providing a safe service, that ensured people’s health and welfare needs were fully met, were required. The registered manager showed us the service development plan that provided details of further planned improvements.

Systems in place to assess the quality of the service provided were not always effective and improvements had not been fully implemented. Checks undertaken by nurses, the deputy manager and registered manager to ensure the safe management of medicines and people’s care and treatment was safe, had not identified potential areas of risk. Whilst some improvement had been made, further improvements were required.

Feedback was sought from people and their relatives but improvements were not always effectively made in the areas that mattered most to people. Staff did not always feel supported by management. Staff felt the ‘culture and feel’ of the home needed to improve so concerns could be openly raised with management and feedback given.

Nurses had been trained to use an electronic system when administering people’s medicines and felt supported with this. However, further improvements were needed so that nurses had the information they needed to ensure ‘when required’ medicines given consistently to people and in ensuring storage of medicines was undertaken safely.

Risk assessments to minimise where people may be at risk of harm or injury and the required actions, had not always been taken. People’s wound care records did not always contain the information needed for staff to prevent and manage the risks of skin damage.

People were supported by staff who were trained to know what abuse was and how to report any concerns.

People were supported to eat and drink and improvement had been made in the snacks offered to them between meals. Further improvement was required to ensure staff followed professional healthcare guidance from speech and language therapists when supporting people to eat. Care records showed healthcare professionals were involved in people’s care and treatment, but further improvement was required to ensure records were detailed so that actions could be referred back to.

Nurses and care staff received training, however they did not always put this into practice or demonstrate their understanding of what they had learnt from the training.

Staff worked within the principles of the Mental Capacity Act (MCA) 2005 when supporting people. The registered manager understood their responsibilities and acted in accordance with the MCA. The requirements of the Deprivation of Liberty Safeguards were followed.

People were supported by some kind and compassionate staff who demonstrated a caring approach. However, this was not consistent with all staff.

Overall, staff responded to people’s physical care needs. Planned activities took place but did not always meet people’s needs and improvements were needed to prevent the risks of loneliness and people becoming socially isolated.

People and their relatives knew how to make a complaint if needed. Complaints were investigated and action taken to resolve issues but relatives felt improvements were not always sustained.

We found continued breaches in the regulation relating to the safe care and treatment of people and in the governance of the home. We met with the provider to discuss these on 26 January 2017.

You can see what action we told the provider to take at the back of the full version of the report.

Harmony House provides accommodation, nursing and personal care and support for up to 57 older people living with physical frailty due to older age and complex health conditions. At the time of the inspection 52 people lived at the home. The home has two floors; on the days of our visit, the ground floor offered six residential care beds and 16 nursing care beds. People on the first floor all required nursing care.

The home is required to have 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 and associated Regulations about how the service is run. At the time of this inspection the home had a new manager; who had been in post since March 2015 and registered with us in August 2015.

When we inspected the home in March 2015 we identified a breach in the regulation relating to good governance of the home. In addition to the new manager that had started, in January 2016, the provider of the home, Larchwood, had arranged for Healthcare Management Solutions (HCMS) to take over as managing provider of the home from the previous managing provider. At this inspection, we found insufficient improvement had been made by the registered manager and the managing provider to meet the regulation relating to good governance. However, the HCMS regional manager shared a developmental plan with us which showed they had identified some issues that required improvement. We found further areas that required improvement that had not been identified as part of the development plan.

People did not always have their prescribed medicines available to them because staff had not ensured adequate stocks were available. Risks to people had been assessed, however, actions staff should take were not always detailed which meant risks of harm and injury were not minimised. Staff understood their role in protecting people from abuse and what actions to take if they had concerns.

People felt there were not always enough staff available on shift to meet their needs when support was requested. Some people felt staff were positive towards them but this was not consistent and care was not personalised. People and relatives shared concerns with staff and the registered manager. However, whilst they felt listened to, concerns and complaints raised were not always effectively responded to or resolved to people’s satisfaction.

Staff worked within the principles of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. People told us that most staff were kind and had a caring approach but did not always have the time to effectively care for them. Staff did not consistently respect people’s dignity when supporting them. Most people enjoyed the varied group activities offered at the home, but a few people felt socially isolated in their bedrooms.

Risks to people’s nutritional health had been assessed but these were not effective because actions to minimise identified risks were not completed. For example, when weight loss was identified, these people were not offered extra calories in their meals or as snacks. Drinks were offered to people and support was given when needed, however people did not always have drinks left within their reach. Staff referred people to healthcare professionals when needed, but did not always follow the guidance shared with them.

Audit processes to monitor the quality and safety of the service were not effective in identifying where improvement was needed. This meant that people experienced a number of shortfalls in relation to the service they received.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. 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.

Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people who used the service, their relatives and the staff told us.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

The provider understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). There was one person living at Harmony House who had a current DoLS in place and two were being applied for.

The service had recruited new staff. We saw their recruitment practice reduced the risks of employing potentially unsuitable staff. It also ensured staff had the skills, knowledge and experience to work with people.

We were aware there had been concerns about the administration of medicines. We saw the service had made improvements but there continued to be some issues around medication management.

Is the service effective?

We had been made aware by Warwickshire County Council and Arden Clinical Support Unit (CSU) that since our last inspection the service had problems with staffing, medication and infection control. Action plans had been put in place to address issues and the service was improving.

People all had an individual care plan which set out their care needs. These provided staff with the information they needed to support people with their care. Assessments included people's needs for equipment, skin integrity and specialist dietary requirements. We saw some inconsistencies and insufficient information in some care records which could impact on the care provided.

People were not fully involved in their care planning and reviews. The new manager was aware of this and had organised staff seminars to start this process.

Is the service caring?

We observed most staff were caring and kind to people living at Harmony House. Some care staff were task focused and we did not see much engagement with people unless they were carrying out a care task.

People living at Harmony House told us staff were caring. They said, 'Staff are always helpful.' 'I think it's very good (the care).' 'On the whole, pretty good...they do their best'they're understaffed sometimes.'

Is the service responsive?

An activities worker provided people who lived on the ground floor with a good range of activities to stimulate and entertain. The service was less responsive to the social and emotional needs of people being provided with nursing care on the first floor. We saw little engagement with staff apart from when care tasks were being carried out.

We saw people were referred to appropriate health and social care professionals such as the GP, dietician, and tissue viability nurse. On the day of our visit we saw a social worker was visiting a person living in the home.

Is the service well-led?

Since our last inspection the service had been through management changes and had no manager in place for a while. The organisation supported the deputy manager to act up as manager until a new manager was recruited.

The new manager had been in post since 2 June 2014. They were aware of the issues which needed addressing and were beginning to take action to address them. The manager had not been in post long enough to carry out all the necessary changes.

Information from the analysis of accidents and incidents had been used to identify changes and improvements to minimise the risk of them happening again.

The acting manager had recently been confirmed in post. People told us that they felt that he was making noticeable improvements in the home. 'X is very good - he is making a difference."

People and relatives we spoke with told us that they enjoyed living in the home, and that the staff were caring. "It's very good actually, I can't fault them", "The staff are lovely, they treat X like he is their Dad", "The staff are very, very good" and "Some staff are better than others but generally the care is good" were comments made to us.

People's care needs were assessed and care records were up to date and provided clear information of how staff were to provide care and support for people.

We saw that people appeared relaxed in the company of the staff.

People were provided with good food with plenty of choice. Special diets were provided for. Where people were at risk of malnutrition or dehydration, measures were in place to ensure that people received sufficient food and drinks.

A complaints procedure was available. Relatives told us that they felt that the acting manager was listening to their concerns and they were now being addressed.