Higher Park Lodge is a residential care home and accommodates a maximum of 34 people. On the day of the inspection there were 30 people living at the service, four people were in hospital. Some people at the service were living with dementia. The home is a large detached property within Devonport Park, Plymouth. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulated both the premises and the care provided, and both were looked at during the inspection.

This inspection took place on 14 June 2018. The inspection was unannounced. At the last inspection on 3 April 2017, the service was rated as Requires Improvement as we found not all records were up to date and the governance procedures in place at the time of that inspection had not recognised this. The provider took action and at this inspection we found there had been changes to ensure all records were well maintained and an accurate reflection of people’s care. Systems had been established to double check audits and reduce the likelihood of this occurring again. We found the service had improved from “Requires Improvement” to “Good”, with the caring domain rated as “Outstanding”.

Why the service is rated as Good:

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 and their relatives told us staff were exceptionally dedicated, caring and kind. Staff demonstrated compassion for people through their conversations and interactions. They did special things which made people feel they mattered. Feedback about the caring nature and acts of kindness were excellent. Comments included, “So kind and helpful during my auntie’s stay, she still talks about you now”; “I’m glad they found Higher Park Lodge as it is so lovely here”; “Wonderful”; “Wishes happen” and “Staff treat mum and her visitors extremely well.”

We observed staff treating people as individuals with different needs and preferences. Staff understood that people’s diversity was important and something which needed to be upheld and valued. Examples were given to demonstrate how staff respected people’s different disabilities, sexual, cultural and faith needs.

People told us their privacy and dignity was promoted. People all said they were actively involved in making choices and decisions about how they wanted to live their lives. People were protected from abuse because staff understood what action to take if they were concerned someone was being abused or mistreated.

People received care which was responsive to their needs. People and their relatives were encouraged to be part of the assessment and care planning process. This helped to ensure the care being provided met people’s individual needs and preferences. Support plans were very personalised and guided staff to help people in the way they liked.

Risks associated with people’s care and living environment were effectively managed to ensure people’s freedom was promoted. People were supported by consistent staff to help meet their needs in the way they preferred. People’s independence was encouraged and staff helped people feel valued by encouraging their skills and involving them in decisions. The registered manager and provider wanted to ensure the right staff were employed, so recruitment practices were safe and ensured that checks had been undertaken. People’s medicines were safely managed and given to them on time.

People received care from staff who had undertaken training to be able to meet their unique needs. People’s human rights were protected because the registered manager and staff had a good understanding of the Mental Capacity Act

We carried out an unannounced comprehensive inspection of this service in December 2015. At this inspection, breaches of legal requirements were found. We served warning notices on the registered provider. Warning notices are part of our enforcement policy. The rating at the December 2015 inspection was Requires Improvement in all areas.

We undertook a further unannounced, focused inspection of this service on 10 and 11 August 2016 to check improvements had been made. We found action had been taken to improve many areas, however, there remained problems with the management of medicines. The rating at this inspection remained Requires Improvement. We asked the provider to take action to make improvements, and this action has been completed. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Higher Park Lodge on our website at www.cqc.org.uk.

We undertook this unannounced comprehensive inspection of the 3 and 4 April 2017 The first day of the inspection was unannounced.

The service provides care and accommodation for up to 34 older people, some of whom are living with dementia or who may have physical or sensory health needs. On the days of the inspection 33 people were living at the service.

Accommodation and facilities at Higher Park Lodge are over three floors, with access to the lower and upper floors via stairs or a passenger lift. There are some shared bathrooms, shower facilities and toilets. Communal areas include a lounge, a reminiscence room, a dining room and an outside patio area.

The service had 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.

At this inspection we found there had been great improvement in most areas, but we continued to have concerns regarding the timeliness of care plans being completed for some people and staff understanding how to use the new assessments in place. We also had concerns that the auditing processes in place had not identified the problems with records we found. The provider took action during the inspection period to address this.

A registered manager was employed to manage the service; they were also the registered provider. 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.

There was a positive culture within the service. The registered manager had clear values about how they wished the service to be provided and these values were shared by the whole staff team.

There was a management structure in the service which provided clear lines of responsibility and accountability. A registered manager was in post that had overall responsibility for the service. They were supported by other senior staff that had designated management responsibilities. People told us they knew who to speak to in the office and any changes or concerns were dealt with swiftly and efficiently.

Feedback received by the service and outcomes from audits were used to aid learning and drive improvement across the service. The manager and staff monitored the quality of the service by regularly by undertaking a range of regular audits and speaking with people to ensure they were happy with the service they received. People and their relatives told us the management team were approachable and included them in discussions about their care and the running of the service.

People told us they felt safe using the service. There were risk assessments in pla

We carried out an unannounced comprehensive inspection of this service on 22 December 2015, 7 January and 21 January 2016. Breaches of legal requirements were found. We served Warning Notices on the registered provider. Warning notices are part of our enforcement policy and tell the provider where they were not meeting their legal requirements. They had to have put this right by 30 June 2016. This was because care was not always safe, personalised and consistent; people’s consent was not always obtained prior to care being given and, systems in place to monitor the quality of the service were ineffective. People were not protected from risks associated with their care and risk assessments were not reflective of people’s current risks. People were also at risk of not receiving their medicines as prescribed. People’s records were not well maintained to evidence care given.

We undertook this focused inspection on the 10 and 11 August 2016.We undertook this focused inspection to confirm that they now met legal requirements. The first day of the inspection was unannounced. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Higher Park Lodge on our website at www.cqc.org.uk.

The service provides care and accommodation for up to 34 older people, some of whom are living with dementia or who may have physical or sensory health needs. On the days of the inspection 32 people were living at the service.

Accommodation and facilities at Higher Park Lodge are over three floors, with access to the lower and upper floors via stairs or a passenger lift. There are some shared bathrooms, shower facilities and toilets. Communal areas include a lounge, a reminiscence room, a dining room and an outside patio area.

The service had 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.

At this inspection we found there had been substantial improvement in most areas, but we continued to have concerns that medicines were not managed safely.

People’s medicines were not always managed, administered and stored safely. We found changes had been made but these required embedding and further improvement. We found the temperature recordings of the fridge were noted as out of range but action had not been taken which meant medicines may not be effective. A new fridge was to be imminently installed. We found handwritten entries were not always signed by two people and there was not always evidence of GP instruction when alterations had been made. We found people’s care plans gave more information about their medicines and allergies but these were not on people’s medicine records (MARs). This could put people at risk. Body maps were now in place to record people’s skin creams but these required more detail to reflect people’s prescriptions. Instructions for administering medicines were not always followed, this meant people might experience side effects from the medicine or they may not be as effective. We found improvement had been made to recording people’s medicines but this didn’t always match the stock of medicine. The provider told us a new electronic medicine system was being implemented in September 2016 which would address some of these issues.

Staff had updated care plans and a new care planning system was in the process of being implemented. Staff training had improved knowledge on how to develop care plans which reflected people’s risks and care needs. For example how to manage people’s diabetes, skin care and continence needs. People’s new care records were more personalised, detailed and thorough. Care records

The inspection took place over three days, 21 December 2015, 7 January 2016 and 21 January 2016. The first day of the inspection was unannounced.

The service provides care for and accommodation for 34 people who are living with dementia or who may have physical or mental health needs. On the days of the inspection 33 people were living at the care home.

Higher Park Lodge is on three floors, with access to the lower and upper floors via stairs or a passenger lift. There are some shared bathrooms, shower facilities and toilets. Communal areas include a lounge, a reading room, a dining room and an outside patio area.

The service had 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.

At the last inspection on 27 and 29 May 2015, we asked the provider to take action to make improvements as we found care was not always safe, personalised and consistent; people’s privacy was not always respected; people’s consent was not always obtained prior to care being given; risk assessments did not always reflect people’s needs; there was no proper and safe management of medicines; effective systems were not in place to take action should an allegation of abuse be received; staff did not always have the knowledge, experience and skills to support people; and the systems in place to monitor the quality of the service were ineffective. The provider sent us a plan detailing the improvements which would be made to meet the legal requirements in relation to the breaches. The provider told us they would make improvements by the beginning of October 2015.

At this inspection we found some improvements had been made, but we continued to have concerns in several areas.

Prior to the inspection we received information of concern about the service. These included concerns about people’s care; care not being given as people chose; lack of care planning in respect of people’s specific needs and staff not accurately recording people’s day to day care. We reviewed these concerns, along with the issues raised at the previous inspection, during this inspection.

People’s medicines were not always managed and administered safely. Some people told us they were not always observed taking their medicines and we found staff were signing the person’s medicine administration records (MARs) without staff knowing people had safely taken their medicine. There were gaps in people’s MARs so it could not be guaranteed people had been given their medicine as prescribed. Staff were not always clearly recording people had their prescribed creams applied as directed. Storage of medicines was not always safe and we found discrepancies in other records concerning how people’s medicines were given.

People’s care records were not always personalised and did not always show whether people were involved in writing them. However, these were being improved during the inspection. People did not always receive their personal care as they wanted it delivered. The records of people’s care were not always complete and lacked essential details to ensure care given was appropriate and as desired by the person. People’s end of life needs were not always planned with them and the care planning was inconsistent.

People’s individual risk assessments were not reviewed regularly to ensure they reflected people’s current risk. People were not involved in planning how to mitigate the risks they faced while living at the service. People’s care plans and records did not reflect risks which had been identified.

People were not always being assessed in line with the Mental Capacity Act 2005 (MCA). Not all staff had been trained in the MCA and the associated Deprivation of Liber

People we met told us "I'm happy here" and "The staff are lovely, all very good people."

Everyone we spoke with felt well cared for at Higher Park Lodge. We spoke with staff who knew people well, were well trained and responded to their needs with compassion. We saw evidence of a range of health professionals being involved in people's care and staff seeking advice when needed.

People told us the food is "Nice" and "The food is good and there is enough." We met with the chef and saw home-made meat pie on the day of our visit. The kitchen was well stocked, fresh ingredients were delivered three times a week and people had a good choice of food at each meal. Special diets were catered for and people were prompted to eat where this was needed.

We met with staff who were happy in their roles, felt supported by the management team and were well trained. Staff had completed training in safeguarding vulnerable adults and there were policies in place at the home for staff to follow. These helped staff to feel confident recognising and protecting people from abuse.

We saw a range of measures in place which monitored the quality of care people received at the home and assessed possible risks at the home such as annual resident surveys and regular resident and staff meetings held at the home.

This was a planned inspection. We also followed up on concerns from our inspection on 18 November 2011. During our previous inspection we had concerns because people’s dignity was not always maintained. Care of people with dementia was not well assessed, planned or delivered and the home was unclean, putting people at risk of infection. On 22 March 2013 we found that the home had made improvements.

People told us they were happy. One person said “I’m very happy here.” People told us they were happy with the care and support they received. We observed that staff treated people who had dementia with respect and protected their dignity.

Staff knocked on people’s doors and asked for permission to enter. People were supported at meal times and their independence was promoted.

People were able to make choices. We saw that staff respected people’s wishes and people told us they felt respected.

We toured the home with the manager and looked at all areas of the home including bathrooms, toilets, bedrooms and communal areas. Overall the home was clean and had made improvements.

The home had completed all required pre-employment checks on staff including references and Criminal Records Bureau (CRB) checks. Records were locked away securely and policies and procedures were in place that gave guidance on their safe storage and disposal.

We saw that the home maintained appropriate and accurate medical and staff records.

On the day of our visit we walked around the home and spoke to people that use the service. We also spoke with relatives, staff and managers.

People that use the service told us that the care given by the home’s staff was of a good standard. Relatives we spoke with told us that they were very happy with the care and support that was being given to their relatives.

We were told that two thirds of the 25 people that live in the care home have dementia. Generally people were treated with respect and their dignity was maintained. We saw much good care for both people with physical needs and people with dementia care needs. We also found that people were generally engaged in stimulating activities. However we saw that on occasion some staff did not support people appropriately and that as a result people's dignity was not always maintained.

Some people’s care needs were being clearly identified, planned for and were being met consistently and well. However the care for some people with dementia was not well assessed, planned or on occasion delivered well by the service.

We heard about people's daily activities and how the introduction of the role of activity coordinator had assisted in developing more stimulating activities for people to enjoy.

When people that live at the home have health needs they are supported to access health services. None of the people that live in the home can manage their own medication. We saw that the service was managing people's medicines safely.

We saw that the home was generally clean and hygienic and that it was being adequately maintained. We visited many bedrooms where there was no incontinence odour. However we found that there was a considerable continuing problem in some parts of the home. We found that there were particular problems in the front hallway and porch and in the dining room.

On the day of our visit we walked around the home and spoke to people that use the service. We also spoke with relatives, staff and visiting professionals.

People told us the care given by the home’s staff was of a good standard. One relative told us that they were very happy with the complex care and support that was being given to their relative.

All of the people that live in the home have significant though varied care needs. We saw that the service had enough staff on duty throughout each day to support the people that lived at the home.

The staff ensure through the way they deliver care and support that everyone’s human rights, privacy and dignity are respected and protected. For example we saw staff talking with people in a respectful manner and we saw support being offered with sensitivity and care.

We heard about peoples’ daily activities and how the introduction of the role of activity coordinator has assisted in developing more stimulating activities for people to enjoy.

When people that live at the home have health needs they are supported to access health services. None of the people that live in the home can manage their own medication. The service was managing medicines safely.

We saw that the home was generally clean and hygienic and that it was being adequately maintained.

The staff that are employed by the provider had generally been properly recruited and were appropriately trained. This training helps staff to deliver good quality care, safely.

The inspection took place on 27 and 29 May 2015 and was unannounced.

Higher Park Lodge provides care and accommodation for up to 34 people who are living with dementia or who may have physical and mental health needs. On the day of the inspection 33 people were living at the care home.

The home is on three floors, with access to the lower and upper floors via stairs or a passenger lift. There are shared bathrooms, shower facilities and toilets. Communal areas include a lounge, a reading room, dining room and outside patio area.

At our last inspection in July 2013 the provider was meeting all of the Essential Standards inspected.

The service had 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 told us they felt safe living at Higher Park Lodge. People were protected by safe recruitment procedures as all employees were subject to necessary checks which determined they were suitable to work with vulnerable people.

Staff understood how to recognise abuse and knew what their responsibilities were. However, people were not always protected from abuse because the provider did not have an effective system in place to investigate allegations of abuse. People received their medicines, but people’s medicines were not effectively managed. Medicines were not always stored safely and documentation relating to medicines was inaccurate.

There were enough staff to meet people’s needs. People’s feedback about staff varied, some people told us staff were kind whilst others felt differently. We observed a mixed approach by staff, some staff showed kindness and compassion whilst others did not. People’s confidentiality, privacy and dignity were not always respected. Locks on bathroom doors did not always work, information about people’s individual care needs were displayed on people’s wardrobes or on their front door to their bedroom and conversations between staff about people were not always held in private.

Staff told us they felt well supported by the registered manager and deputy manager. Staff received training and supervision to carry out their role, but some staff had not undertaken specific training to meet people’s needs, such as dementia care and manual handling.

People were not protected from risks associated with their care because staff did not have the correct guidance and direction about how to meet people’s individual care needs. The registered manager and staff did not fully understand how the Mental Capacity Act 2005 (MCA) and deprivation of liberty safeguards (DoLS) protected people to ensure their freedom to make decisions and choices was supported and respected. This meant decisions were being made for people without proper consultation. The MCA provides the legal framework to assess people’s capacity to make certain decisions, at a certain time. When people are assessed as not having the capacity to make a decision, a best interest decision should be made involving people who know the person well and other professionals, where relevant. DoLS provide legal protection for those vulnerable people who are, or may become, deprived of their liberty.

People experienced a disorganised approach by staff at lunch time, and people who required support with their meals did not always receive it. People were not always given choices about what they would like to eat and drink. People who were at risk of not eating and drinking enough were not being effectively monitored, which meant concerns may not have been identified quickly. People were not able to help themselves to drinks when they needed them as they were not always readily available.

People did not always have care plans in place to address their individual health and social care needs. People were not involved in the creation of their care plan. People’s changing care needs were not always communicated amongst the staff team, which meant referrals to relevant health services were not always made in a timely manner.

People’s care plans were not individualised and did not provide guidance and direction to staff about how to meet people’s care needs. People told us there were not enough activities or opportunities to go out.

People’s end of life wishes were not documented and communicated. People’s care planning documentation was not reflective of their wishes. This meant people’s end of life wishes were not known to staff.

People who were living with dementia were not always appropriately supported in a person centred way. People’s care plans did not address dementia care needs and demonstrate how they would like to be supported. The environment was not designed to empower people living with dementia, because of poor signage and a lack of colour contrast.

People and those who mattered to them, were encouraged to provide feedback about the service they received. People were able to raise concerns and the registered manager investigated complaints and learnt from complaints to make improvements. The registered manager worked positively with external professionals.

The registered manager did not have effective systems and processes in place to ensure people received a high quality of care and people’s needs were being met.

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