We undertook an unannounced inspection of Lansdowne Hill Care Home on 20 March 2018.

Lansdowne Hill Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home is registered to provide accommodation for up to 46 persons who require personal care. On the day of our inspection 43 people were living at the service.

At the last inspection, the service was rated Good. At this inspection we found the service had improved and was meeting the characteristics of outstanding in Caring and Well-led domains. When the two or domains are rated as Outstanding the overall rating is also Outstanding.

People were at the heart of Lansdowne Hill Care Home. We saw examples of staff wanting to make a positive difference to people’s quality of life. This reflected the values that staff held and the culture of the service ‘being more than a job’. People said they felt well cared for and were offered emotional support when needed. Relatives said they felt encouraged to maintain important relationships with their loved ones and could visit at any time. They said the management team were good at keeping them informed about people's care. People’s dignity was always respected and people were able to build meaningful, caring relationships with staff.

The service was led by a longstanding, registered manager who promoted a service that put people at the forefront of all the service did. 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.

The registered manager was very passionate about working with people and their aim was to ensure the service met people’s physical and emotional needs. There was a very high level of confidence in the leadership and management of the service expressed by people, relatives and external professionals. The registered manager ensured ongoing development opportunities were available for staff and their development. The team worked closely with other agencies and promoted an open and transparent culture that promoted a strong emphasis on continually striving to improve the service. There were effective systems in place to monitor the quality of the service provided and appropriate action was taken promptly when required.

The atmosphere at Lansdowne Hill was one of calmness, order and positivity. This enabled staff to embed a strong culture that valued people, relatives and staff and promoted a caring ethos.

People remained safe living in the home. There were sufficient staff to meet people's needs and staff had time to spend with people. Risk assessments were carried out and these promoted positive risk taking which enable people to live their lives as they chose. People received their medicines safely.

People continued to receive effective care from staff that had the skills and knowledge to support them and meet their needs. People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible; the procedures in the service supported this practice. People were supported to access health professionals when needed and staff worked closely with people's GPs to ensure their health and well-being was monitored. Professionals said staff worked collaboratively with them to ensure people received high standards of care.

The service continued to be responsive to people's needs and ensured people were supported in a personalised way. People's changing needs were responded to promptly. People had access to a variety of activities that met their individual needs. The registered manager saw f

An unannounced inspection took place on 20 January 2016. Lansdowne Hill Care Home is situated in Swindon and provides personal care and accommodation for up to 46 older people, some of whom are living with dementia. At the time of inspection 44 people were living in the home.

The home was run by a management team consisting of the registered manager and a deputy manager. 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.

The service was calm and welcoming when we visited. People were up and about the home and looked well-presented and relaxed. There was a person sat in the sunshine in a lounge looking at the dovecote. Staff were chatting with people and discussing things like the weather. The garden was large and well-tended.

People spoke highly of their experience of living at Lansdowne Hill. They expressed verbally about the excellent care they received from care staff and valued their relationships with them. Staff were compassionate and regularly carried out spontaneous acts of kindness. We also observed many caring interactions between the staff and people in the home throughout the day of our inspection. There was a friendly and warm atmosphere throughout the home. Care staff provided personalised care and knew people's needs, likes and dislikes.

People were at the centre of all activities and there was a range of activities offered to meet individual needs. There were many examples of activities and events organised to ensure people continued to enjoy participating in things they enjoyed. People were involved in deciding activities they would like organised and those they would like to attend.

The service sought to understand and improve on people’s experiences and the service overall through a variety of feedback methods, seeking views of relatives and other professionals involved with the service. The service was keen to continually improve their service. This was assisted by an open and transparent culture led by the registered manager and the deputy manager who encouraged listening to people and staff to ensure the service could improve further. Staff said the registered manager expected and demonstrated clear expectations of high levels of care for people and a positive culture had developed from this ethos. This contributed to the high levels of satisfaction we heard and observed at the home from people, their relatives, professionals and staff.

People and their relatives were complimentary about the staff and registered manager. Relatives said communication with the home was good and they were kept up to date on their loved ones. People and their relatives were encouraged to give feedback on the service and their views were valued.

The registered manager and staff ensured there were well-established local links which were important to people who lived in the home to avoid social isolation. This meant people felt part of the community and visited local pubs, a local school for events and their church of choice. People were encouraged to take part in activities to raise funds for both the home and local charities.

Staff felt well supported and had access to development opportunities to improve their skills and knowledge. This included specialist training from a local hospice to support people with end of life care and for also training and use of dementia champions for those experiencing dementia. Staff received regular supervision and were encouraged to have input into improving the quality of service and spoke highly of the support and the manager and said they enjoyed their jobs.

Some people who used the service were unable to make certain decisions about their care. In these circumstances the legal requirements of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS) were being appropriately followed. Staff understood the principles of these requirements and were able to explain why it was important for people in the home.

People’s health and wellbeing needs were closely monitored. People benefitted from excellent links with local primary care services which was complemented by good partnership working between the home and relevant professionals. The service had sought relevant and timely advice to ensure those at the home received the level of care they required.

People’s risks were assessed, managed and reviewed. Staff knew people well and used this knowledge combined with effective guidance from senior staff to reduce the risk of harm. There were enough suitable staff to meet people’s needs and promote people’s safety and wellbeing. There were systems in place to protect people from the risks associated from medicines and staff were vigilant in monitoring and using these.

Systems were in place to monitor the quality and safety of the service and had been regularly audited. Equipment in use had been serviced and the premises were well maintained.

On the day of our inspection there were 42 people using the service. We considered all the evidence we had gathered during our inspection to answer the five 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?

Is the service safe?

People were cared for safely. People's needs were assessed and reflected in their care records. Risk assessments were in place and reviewed regularly. We asked people if they felt safe. One person told us, “I definitely feel safe. Staff are caring and kind.” One relative told us, “My relative is safe, happy and well cared for.”

Accurate and appropriate records were maintained. All personal records were kept in a lockable cupboard. Care records we looked at were accurate and up to date.

Arrangements were in place for obtaining and disposing of medicines safely. Medicines were delivered to the home monthly. Most medication was dispensed in a Monitored Dosage System (MDS). Where medication was not in the Monitored Dosage System (MDS) it was clearly labelled with all relevant information. Medicines were stored safely in locked medication trolleys and in locked cupboards. Care workers who administered medication had been trained. Medication Administration Records were accurate and completed appropriately. This meant that medicines were managed safely.

CQC monitors the Mental Capacity Act 2005 Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The registered manager had made application for a Deprivation of Liberty Safeguard (DoLS) showing us that relevant staff understood when an application should be made and how to submit an application. This meant there were suitable policies and procedures in place.

Is the service effective?

People received support that was effective. People received support and care that kept them emotionally and physically well. Staff showed clear understanding of individual needs and supported people with empathy. People's changing needs were addressed in a timely manner and referrals made to health professionals where needed. Care records for people living with dementia had information about their past and staff recognised the importance of knowing this. People moving into the home and their families were supported through the process. One relative told us, "I came in and had breakfast every day when my relative moved in to help them settle."

People using the service had an individual care plan which set out their care needs. People had their needs assessed and were involved in the development of their care plan. Family and friends were involved in care planning where it was appropriate. One relative told us, “I am very involved. It is a care partnership.”We saw that care staff had a clear understanding of people’s care and support needs. One member of care staff told us, “I love getting to know everyone.”

Care staff working in the home were well supported. Care staff records showed care staff had received training to meet the needs of the people living in the home. One care staff member told us, “We have great team work. I wasn’t very confident but the support has helped me.” Care staff received formal support four times a year, which included one to one supervision, appraisals, staff meetings and spot checks.

Is the service caring?

People were supported by a caring service. People we spoke with were happy with the care and support they received. One person told us, “I’m quite happy. It couldn’t be better.” During our visit we spent some time in the lounge conducting a SOFI. We saw people were engaged in activities or tasks and had good interactions with care staff. We observed care staff being kind and considerate. One care staff member spent time with a person who was anxious about a relative who was unwell. The care staff member was reassuring, showing empathy and understanding. Arrangements were being made for the person to visit their relative in hospital.

Is the service responsive?

People benefited from a service that was responsive. Care records showed people’s religious beliefs and identified spiritual needs. There were monthly religious services held in the home. The home had involved an interpreter to support decision making for a person whose first language was not English. This meant that individual needs were met.

During our visit we saw people engaged in activities. Care staff were supportive, they encouraged and praised people who were joining in. The atmosphere was calm and relaxed. People we spoke with told us there were different activities most days. We were told that visitors come in from the community and support activities. One person told us, “I like karaoke on a Thursday.” Care staff told us this was a popular activity.

Is the service well-led?

People received a service that was well-led. The manager was clearly passionate about the care and support of the people living in the home. Care workers spoke positively about the manager and the staff team. Care workers told us they were confident to raise concerns and that they would be taken seriously.

We looked at the quality assurance systems that were in place. There was evidence that information was reviewed and used to improve the service. People’s views were listened to and action taken. The service was monitored on a consistent basis to ensure that people’s care and treatment was safe and appropriate to their needs.

Records we looked at were completed accurately and were regularly reviewed. This meant that records were fit for purpose

We saw that appropriate arrangements were in place for the ordering, supply and receipt of medicines. Staff we spoke with told us that there was a good relationship between the GP surgery and the community pharmacy.

We found that medicines had not been stored at the recommended temperatures. Therefore, we could not be assured that medicines being administered had not deteriorated due to incorrect storage temperatures. This meant that medicines had not been kept safely.

During the morning round we saw that an iron tablet for one person was missing from the container, although no administration had been recorded. Therefore, we could not be assured that people had received their medicines at the times they were prescribed.

Appropriate arrangements were not in place in relation to the recording of medicines. We found there had been 32 administration recordings missed between 5 September 2013 and 19 September 2013 and 11 missed between 30 September 2013 and 3 October 2013. We noted that 13 of the 15 staff trained to administer medication had failed to sign the MARs during these dates.

Staff told us that the medication rounds in the morning and evening were far too long for one person. They told us that it was difficult to maintain their levels of concentration for up to four hours. Staff thought most recording errors had been caused by constant interruptions by people who used the service and other staff.

We spoke with people who used the service and their relatives who told us that they were always consulted about the care they received. Where people needed support to make decisions we saw that best interest meetings had been held and their views were recorded.

Observations during our inspection showed that people were receiving effective, safe and appropriate care, which was designed to meet their specific needs. We saw people being supported with sensitivity and patience. One person told us,“Some days I am fine but sometimes I feel a bit wobbly. They always seem to know what sort of day I’m having.” A relative told us,“The care is very good and the people who work there are kind and gentle. You never hear a harsh word.”

We undertook an inspection of the environment and found the home to be clean, hygienic and free from odours. We saw that staff had received appropriate training in relation to cleanliness and infection control. Staff we spoke with were able to tell us about the appropriate action they would take in relation to an outbreak of infection.

The provider had an effective system for the management of medicines, which was supervised by a designated medication lead. We observed medicines given in a focused, respectful manner and saw that the process was accurately recorded.

We found that the range of self- auditing ensured that the manager could identify, assess and manage risks relating to the health, welfare and safety of people being supported.

Our two day visit focused on checking whether improvements had been made following our last review in March 2012 and to ensure that other areas of the service were safe and fit for purpose.

We found that the necessary improvements had been made with regard to care and welfare. We observed staff being attentive and kind when dealing with people and provided support in line with their needs.

People who used the service told us that the staff were always kind and helpful but sometimes there weren’t enough of them, which meant they had to wait for support.

One person said, “They treat you so well. There’s no rushing in and rushing out.” Another person said, “The staff are very good. I trust all of them.”

People’s dignity and human rights were being respected and we saw them being actively encouraged to make choices regarding their daily routines.

People who used the service were protected from the risk of abuse because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

People were made aware of the complaints system. This was provided to them in a format that met their needs. People told us they had no fear of discrimination if they made a complaint and were sure they would be supported by the registered manager and staff.

During our visit we saw that people were well cared for and treated with dignity and respect by staff who had appropriate skills, knowledge and experience to meet their needs.

We carried out this inspection in response to concerns which were brought to our attention. During our visit on the 22nd March 2012, people told us they liked living in the home and staff were very kind and treated everyone respectfully. People said they were happy with the care and support they received.

Earlier in the year the home had experienced a breakdown of the sprinkler system which had resulted in a flood. People told us about the refurbishment of the dining room and smaller lounges and were please they had now been completed, people said it had been a lot of upheaval because of a lack of space. We saw that people were now using the new lounges which were comfortably furnished.

There had been changes to staff numbers and responsibilities and the manager was confident that the current staffing levels were sufficient. Staff were confident that they were still able to meet people’s needs.

The home had undergone transition to a new provider and changes were still being made to the format of the care plans. Care plans were not detailed enough to show how people’s needs were being met.

People told us that they liked living at the home. One person said the “food is very nice with a good selection and choice available”. They told us about the entertainment and outings they had. One person told us about the collection of books in the home and how they found it useful to have them. They said they would recommend the home and talked about the "friendliness of the staff and other people" who lived in the home.

We saw that the home was clean and tidy. We saw housekeepers cleaning throughout the day. Some areas of the home were identified for upgrading as they looked 'tired'.Refurbishment had started and we saw that this was to a good standard that one person said they liked. Staff were but went about their tasks in a calm and unhurried manner. We saw people enjoying a quiz that was held in the main lounge during the morning.