This unannounced inspection took place on 18 and 19 September 2017. We last inspected Highgrove House in September 2016 when the service was compliant with all regulations.

Highgrove House is registered to provide accommodation for up to 43 people who require personal care. The home is over two floors with specific units on the ground and first floors of the home. Some of the people living at the home were living with dementia and they lived on the first floor. This upper floor is accessible by stairs or lift. Each unit has access to a kitchen area, lounge and dining room and bathrooms and toilets. Accommodation is provided in single rooms, four of which are en-suite. There were 41 people who lived at the service at the time of our inspection.

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.

We spoke to people and their relatives and received positive feedback about the care provided at Highgrove House. During this inspection we found the service met all regulations.

There were policies and procedures on how the service protected people against bullying, harassment, avoidable harm and abuse. Staff had received training in safeguarding adults.

Staff had sought advice from other health and social care professionals where necessary. There were risk assessments which had been undertaken. Plans to minimise or remove risks had been drawn up and reviewed in line with the organisation’s policy. These were robust and covered specific risks around people’s care and specific activities they undertook.

Concerns regarding people’s care needs had been addressed and lessons were learnt from safeguarding enquiries. Robust action had been taken to address any shortfalls identified by safeguarding professionals.

People were protected against the risk of fire. Building fire risk assessments were in place and fire fighting equipment had been maintained.

There was a medicines policy in place and staff who administered medicines had been trained to safely support people with their medicines.

We looked at recruitment processes and found the service had recruitment policies and procedures in place to help ensure safety in the recruitment of staff. These had been followed to ensure staff were recruited safely for the protection and wellbeing of people who used the service. Records we saw and conversations with staff showed the service had adequate care staff to ensure that people's needs were sufficiently met.

The service followed the requirements of the Mental Capacity Act 2005 Code of practice and Deprivation of Liberty Safeguards. This helped to protect the rights of people who were not able to make important decisions themselves. People who used the service gave positive feedback on the quality of the service. Some people were unable to give us feedback due to their complex needs. We spoke to their relatives. Feedback from relatives about care standards was positive. Choices were generally promoted however we found two people felt they had not been fully supported to exercise their choice in relation to accessing the community independently.

People using the service had access to healthcare professionals as required to meet their needs. Staff had received training deemed necessary for their role. Staff competences had been checked in medicine management. Staff had had also been provided with annual appraisals. We found improvements were required to ensure all care staff were up to date with their training.

We found that people’s care needs were discussed with care commissioners before they started using the service to ensure the service was able to meet their assessed needs. Care plans showed how people and

This unannounced inspection took place on 21 September 2016. We last inspected Highgrove house in November 2014. Requirements made at previous inspections had been addressed.

Highgrove House is registered to provide accommodation for up to 43 people who require personal care. The home was over two floors with specific units on the ground and first floors of the home. Some of the people living at the home were living with dementia and they lived on the first floor. This upper floor is accessible by stairs or lift. Each unit has access to a kitchen area, lounge and dining room and bathrooms and toilets. Accommodation is provided in single rooms, four of which are en-suite. At the time of the inspection there were 41 people living in the home.

The service had a registered manager in post. 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 and associated Regulations about how the service is run.

We spoke with people living in the home and they made positive comments about their home. They told us that care staff were available to help them when they needed assistance and that staff respected their privacy. Some people who were living with dementia could not tell us their views but those people who could told us they felt safe living there. We were told “I do feel safe here. I am quite happy”.

People who lived at Highgrove House said they knew the registered manager of the service well and saw them every day to talk with and felt comfortable doing so. People told us that they would be comfortable raising and complaints with the registered manager.

We noted that there was a clear structure and lines of responsibility within the home and being promoted by the registered manager. The registered manager had notified the CQC of any incidents and events as required by the regulations.

The registered manager used a range of methods to get feedback from people living, working and visiting home in the and promoted open communication. The registered manager and quality consultant had implemented a programme of auditing the care planning systems and practices in the home to help promote continued improvement .The registered manager was well regarded by people we spoke with who lived in the home and the visitors we spoke with.

They service had safe systems for the recruitment of staff to make sure the staff taken on were suited to working there. We saw that care staff had received induction training and on going training and development and had regular supervision and annual appraisal.

We saw examples of staff giving people their attention, offering reassurance and displaying empathy. We also saw an example of where this was not applied. We recommended that the registered manager formally checked the level of dementia awareness training of non-permanent staff have before they worked with people living with dementia. This was to make sure they could respond appropriately to the needs of people living with dementia.

People had a choice of meals and drinks and they told us the food was “good” and “fantastic” and that they enjoyed their meals. People were involved in discussions and feedback about food at their ‘residents’ meetings.

The service worked with local GPs, district nurses and health care professionals and external agencies to provide appropriate care to meet people’s different physical, psychological and emotional needs.

The service followed the requirements of the Mental Capacity Act 2005 Code of practice and Deprivation of Liberty Safeguards. This helped to protect the rights of people who were not able to make important decisions themselves.

There was a system for logging comments made about the service and the care received. We looked at the most recent and how they had been managed. We cou

We carried out this inspection following the receipt of anonymous information in relation to medication, staffing and management issues at the home. We spoke to staff, people who lived at the home and looked at records to ensure that the home was providing a safe and efficient service.

We discussed with the acting manager the concerns we had received. The concerns had been received directly by the Care Quality Commission (CQC) and had been anonymous.

People were protected against risks associated with medicines because the provider had appropriate arrangement in place to manage medicines. We observed the lunchtime medication round at the home. The senior carer who was undertaking the medication round talked us through each person's medicines and how they recorded any medication given or refused. We saw that people were given time to take their medication and the senior carer sat with people to ensure they had taken their medicines.

People told us they were happy with the service they received from the home. One person told us, "They (staff) are great with me here. I can honestly say they are a great lot and they look after me".

This inspection was carried out to assess the safety of people who lived at Highgrove House. It was in response to information received about poorly and inappropriately recruited and trained staff. Further information of concern was raised in relation to poor staff attitude, unsafe medication practices, poor care and lack of nutritional support.

When we undertook this inspection the provider was still in the process of responding to concerns identified during our last inspection on 15/04/2014. During that inspection we had found delivery of care had not been appropriately planned, recorded and risk assessed. There was limited or no recorded evidence of consent and medication issues needed to be addressed. The provider did not effectively assess and monitor the quality of the service provided.

During this inspection we could see that the service provider had begun to address the issues from the last inspection as improvements had started to be made. The provider was working within time scales provided by the Commission to produce a report on actions he planned to take to meet requirements. We did not assess all the outstanding compliance actions from the inspection undertaken on 15/04/2014.

We looked at Highgrove House’s medication processes and found that improvements had been made to meet standards. Medication was dispensed, recorded and disposed of safely and staff had received refresher training to underpin their knowledge and skill.

We spoke with staff, the manager and provider. We also discussed care provision with people who lived at the home, undertook a tour of the building and observed care practices. We found people were receiving appropriate care which was meeting their needs.

We considered our inspection findings to answer questions we always ask: -

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well-led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, the staff supporting them and from looking at records.

Is the service safe?

People appeared comfortable and relaxed during our inspection. We observed care being provided in a safe and supportive manner. A relative told us, “The staff are very caring and are friendly and warm when we arrive”.

However, care planning and risk assessment was poor and inconsistent. People’s changing needs and care provision was not always assessed or regularly reviewed. One relative told us they were not involved in this. This meant people were at risk of unsafe care because the provider had not ensured care planning was clear.

We observed medication being dispensed in a safe and supportive manner. However, medication risk assessments were not in place and medication was disposed of in an unsafe and inappropriate way. This meant people were at risk from unsafe practice in relation to medication.

Staff and relatives told us that staffing levels had improved recently. Rotas we checked confirmed this. We were told that use of agency carers was recent and as a result of staff sickness. We were able to verify that staffing levels adequately ensured safe support levels for people living at Highgrove House.

Is the service effective?

Highgrove House worked effectively with other providers. Where people’s health deteriorated, this was generally managed well. The appropriate external professional was referred to and actions taken were recorded.

Although some care records were personalised and in-depth, we found inconsistencies throughout the files we reviewed. People or their relatives were not involved in care reviews. There was no recorded evidence of consent to care provision. Records were often unsigned, not dated or incomplete.

Highgrove House provided specialist dementia care. However, staff had limited understanding of the Mental Capacity Act and Deprivation of Liberty Safeguards. This meant there were potential gaps in staff training in caring for people with dementia.

Is the service caring?

People appeared to be comfortable and relaxed during our inspection. Staff engaged with people in their care in a friendly, supportive and appropriate manner. Relatives told us they were happy with the care provided.

However, care planning and risk assessment was incomplete and inconsistent. This meant people were at risk from inappropriate or unsafe care. The provider had not ensured records were up-to-date, reviewed and signed by staff.

Is the service responsive?

People’s needs were assessed before they accessed the service. This meant Highgrove House was able to confirm that they could meet the individual’s support needs. The home worked effectively with other providers in responding to people’s deteriorating or changing health.

However, care was not reviewed regularly and consistently. Additionally, this did not involve the individual concerned or their relative. This meant the home did not always monitor if people’s care planning was continuously meeting people’s changing needs.

Is the service well-led?

At the time of our inspection it was unclear who was in charge of the day-to-day management of Highgrove House. On arrival to the home we were made aware that the registered manager was on sick leave. We were informed that a senior carer had been made acting manager in her absence. However, this person was also on leave. We checked with the staff on duty to see who was in charge, but we could not confirm this. This meant people were at potential risk from a service that may not always be well lead.

The majority of staff told us that there was a lot of conflict within the care team. The provider assured us he was aware of this issue and was putting actions in place to manage this.

Although there were a range of quality internal and external audits in place, we found issues that had not been picked up. The provider was unable to confirm the home’s safety certification. He was additionally unable to provide evidence of staff and service user or relative feedback.

People who lived at Highfield House Care Home were positive about their experiences and the comments received reflected this. One person living at the home stated, ""The carers are very kind". Another person told us, "The staff here are lovely, they are so patient. Lots of the people here are not able to care for themselves. It takes a special kind of person to be able to do this job and you couldn't find anyone better than the staff working here".

Staff we spoke to were able to recognise potential safeguarding issues and systems were in place to deal with safeguarding issues if they arose. The people who lived at the home told us they felt safe.

People were protected from the risk of infection because appropriate guidance had been followed. Service users care was provided by staff who were aware of Infection control procedures and protocols.

The premises were clean and tidy and the design, layout and security of the premises were fit for purpose to meet the needs of the people living at the home.

The provider had an effective system in place to identify, assess and manage risks to the health and safety of people using the service and others.