About the service: Highlands Care Home is a residential care home registered to provide accommodation for up to 26 older people some of whom may be living with dementia, have mental health needs or a physical disability. At the time of the inspection 25 people were living at the home.

People’s experience of using this service:

• Insufficient staff were employed at the home to meet people’s needs. Due to the high level of care needs of 12 of the 25 people living at the home, the number of staff available during the day and at night was insufficient to ensure people’s needs were met in a timely way. Staff were unable to supervise people to ensure their safety and people were not provided with the opportunity to engage in meaningful leisure and social activity.

• The home was not clean. Some of the furniture in people’s bedrooms and the floors in the communal areas, including bathrooms and toilets, were dirty.

• People’s freedom to walk around the home was restricted with the use of half-height doors placed across hallways. These also posed a safety risk to people who might climb over them. Following this inspection, we were told these had been removed.

• Risks to people’s health, safety and well-being associated with their care needs were assessed and management plans were in place to ensure risks were mitigated as much as possible. However, some improvements were required with monitoring people’s food intake and with the use of equipment used to protect people from skin breakdown.

• Some environmental health and safety checks had not been carried out. These related to the fire safety systems, managing the risk of legionnaires disease and the temperature of the hot water in people’s bedrooms.

• Medicines were being managed safely.

• People told us they felt safe and well cared for at the home. Relatives also expressed their satisfaction with the safety and care provided.

• Staff knew people well and had developed close, caring relationships. We saw people enjoyed being with staff. Staff were aware of their responsibilities to safeguard people.

• Recruitment practices were safe and staff received the training they required for their roles.

• People and their relatives were involved in making decisions about their care.

• Further consideration needed to be given to providing engagement in social and leisure activities for people living with dementia.

• The home was being supported by the local authority to establish more effective quality assurance systems to assess, monitor and improve the safety and quality of the home.

We identified five breaches of the regulations and we made two recommendations for improvement in relation to restricting people’s movement around the home and engaging people in meaningful social activities.

The home met the characteristics of a rating of “Good” for one key question and “Requires Improvement” for four key questions. Our overall rating for the home after this inspection was “Requires Improvement”.

Rating at last inspection: At the last inspection in August 2016 the home was rated Good (report published September 2016).

Why we inspected: This was a planned inspection based on the rating at the last inspection.

Enforcement: Please see the ‘action we have told the provider to take’ section at the end of the report.

Follow up: We have asked the provider to complete an action plan detailing how they will make improvements to ensure the regulations are met. We will work with our partner agencies, including the local authority, to review the progress made in the home. We will continue to monitor the intelligence we receive about the service. If any concerning information is received, we may inspect sooner.

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

Say when the inspection took place and whether the inspection was announced or unannounced. Where relevant, describe any breaches of legal requirements at your last inspection, and if so whether improvements have been made to meet the relevant requirement(s).

Provide a brief overview of the service (e.g. Type of care provided, size, facilities, number of people using it, whether there is or should be a registered manager etc).

N.B. If there is or should be a registered manager include this statement to describe what a registered manager is:

‘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.’

Give a summary of your findings for the service, highlighting what the service does well and drawing attention to areas where improvements could be made. Where a breach of regulation has been identified, summarise, in plain English, how the provider was not meeting the requirements of the law and state ‘You can see what action we told the provider to take at the back of the full version of the report.’ Please note that the summary section will be used to populate the CQC website. Providers will be asked to share this section with the people who use their service and the staff that work at there.

Our inspection was unannounced and lasted approximately ten hours. We were accompanied by an expert by experience. During this visit, we inspected five outcome areas; all five were compliant.

There were 25 people living at the home, and one person on a short stay. We spoke with people living at Highlands. We also spent time with people in communal areas of the home so we could make a judgement about how well people were cared for as some people were not able to comment directly on their care. We also spoke with three staff members and the manager. We looked at a selection of care records, and focussed on how people’s consent was gained by staff. We also looked at how people’s health and well-being was supported.

We saw people looking relaxed and at ease with staff and each other. We saw people sitting chatting with one another about the activities around them. In the morning, we saw many people laughing and singing. When people felt unwell or anxious, staff were quick to recognise the need to change their approach, such as sitting with them to reassure them.

People’s health and well-being was assessed, and care was provided in a way that suited people's individual needs. Staff were clear about their role to protect people and to report abuse. There was a clear recruitment process in place and appropriate checks were in place to help ensure staff were appropriate people to work with vulnerable people. The home had quality assurance procedures in place to measure the standard of care in the home.

This inspection took place over two days on 13 and 18 May 2015 and was unannounced. Highlands Care Home is a care home which is registered to provide care for up to 26 people. The home specialises in the care of older people most of whom are living with dementia but does not provide nursing care. There is a new manager who took over the role in January 2015 who is currently applying to CQC for registered manager status. 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.

On the day of the inspection there was a calm and relaxed atmosphere in the home and staff interacted with people in a friendly and respectful way. People were encouraged and supported to maintain their independence. They made choices about their day to day lives when able which were respected by staff.

Most people at the home spent their time in the communal areas, two large lounges and an adjoining kitchen/dining area. These had been re-furbished and were clean, comfortable and well furnished with attractive décor. However, the accommodation in the lower ground and first floors required considerable attention. For example, some bed linen was thin and old, pillows were thin and flat, some rooms only provided overhead lighting and there were items of furniture which were shabby and needed replacing. We fed this back to the manager who began to carry out a room audit to present to the provider. They said an upgrade of rooms had been planned but there was no timescale.

The home specialised in providing care for people living with dementia. The new manager had begun to gather person centred information about people but this had not yet been used to inform how staff met people’s social and leisure needs. However, people’s leisure and social needs were not being met in a person centred way and there was a lack of meaningful activities. There were enough staff to meet people’s care needs other than the above.

People and their relatives said the home was a safe place for them to live. One person said “It’s a good place to be here”. Another person said, “Very well orchestrated…we have everything.”

Staff had received training in how to recognise and report abuse. All were clear about how to report any concerns. Staff were confident that any allegations made would be fully investigated to ensure people were protected. We had also been informed of any safeguarding issues which had been dealt with appropriately.

People said they would not hesitate in speaking with staff if they had any concerns. People and their relatives knew how to make a formal complaint if they needed to but felt that issues would usually be resolved informally. Formal complaints were dealt with in accordance with the home’s complaint’s policy. One person said, “I have never had a query go unanswered”.

People were well cared for. Most people were unable to be directly involved in their care planning but the new manager had begun to meet with each person’s representative to discuss the new care plans. A copy of the care plan was then sent to the representative if they were happy to be involved. The manager said “It’s about getting it right for everybody.” There were regular reviews of people’s health and staff responded promptly to changes in need. One relative felt this had not been pro-active in the past but we found the new care plan format enabled staff to clearly monitor and identify changing need. People were assisted to attend appointments with appropriate health and social care professionals to ensure they received treatment and support for their specific needs. A health professional was visiting during our inspection and their advice was documented and actioned immediately.

Staff had good knowledge of people including their needs and preferences. Staff had training programmes and there were opportunities for on-going training and for obtaining additional qualifications. Training had fallen behind last year so the manager had identified shortfalls and staff were booked on appropriate training to bring them up to date in the near future. Comments about staff included, “I have never felt they are talking down to me”, “The staff are very good, caring and excellent, really good.” One relative said “I have never heard any carer speak harshly to anyone...they always treat people with respect.” One visitor said, “Staff are very good and helpful, they respect people’s dignity and privacy” and “There is a sense of calm and given that people have dementia that is good.”

People’s privacy was respected. Staff ensured people kept in touch with family and friends. Each visitor we spoke with told us they were always made welcome and were able to visit at any time. People were able to see their visitors in communal areas or in private.

Medication was well managed. There were systems in place to ensure secure storage, safe administration and record keeping.

There was a management structure in the home which provided clear lines of responsibility and accountability. There had been a period of change but the manager felt his had settled since they started in January 2015. They said there had been a lot of catching up work to do when they started such as training, new care plan format, staff one to one supervisions but this had been managed well and was on track. Staff had been well informed of changes through regular meetings and internal communication. The manager worked closely with a competent senior care worker and both were knowledgeable about how systems worked, people’s needs, preferences and how to meet them.

There were effective quality assurance processes in place to monitor care and plan ongoing improvements. There were systems in place to share information and seek people’s views about the running of the home. People’s views were acted upon where possible and practical. The manager had an open door policy and their office was easily accessible. They obtained feedback from conversations with people, stakeholder surveys, complaints and compliments to continually develop the service.

We found two 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 this report.