Our inspection of the Highgate Care Home took place on 29 and 31 May 2018 and was unannounced. The Highgate Care Home provides accommodation for 52 people who require nursing and personal care. People living at the home required care and support in relation to a range of needs including acquired brain injury, significant physical and sensory impairment, and progressive disabling conditions.

The home is set out across four floors or 'units' with lift access between each. Each floor had a communal lounge and dining area which we saw being used from time to time. A general communal dining area and activity space was provided on the lower ground floor of the building. At the time of our inspection there were 49 people living at the home, some of whom received care in their rooms due the severe and profound nature of their disabilities.

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.

We last inspected this service in May and June 2017 when the home was rated as 'Requires Improvement'. At our last inspection we identified failures in the management and recording of people’s medicines. We also found that these failures had not been identified and addressed by the quality monitoring systems in place at the home.

At this inspection we found that actions had been put in place to address our concerns. People’s medicines were effectively administered, managed and recorded. Regular medicines audits had taken place and we saw that stock counts of medicines were accurate.

Risks associated with people's care and support needs had been identified. Individual risk assessments were in place with along with guidance for staff on how to safely manage these risks.

People told us they felt safe. Procedures and policies relating to safeguarding people from harm were in place. Staff members had completed training in safeguarding adults and demonstrated an understanding of their roles and responsibilities in identifying and reporting safeguarding concerns.

We saw evidence of a comprehensive staff induction and on-going training programme. Staff had regular supervisions and annual appraisals. Staff members were safely recruited with necessary pre-employment checks being carried out.

People were given choices during meal times and their needs and preferences were addressed. People's weight was recorded regularly and action was taken should people lose weight significantly.

The registered manager demonstrated a good level of understanding of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Assessments of capacity were in place and applications to the relevant local authority had been made for DoLS authorisations had been made where appropriate.

We saw that interactions between staff and people were friendly, caring and supportive. Some people were unable to leave their rooms due to the complex nature of their disabilities and we observed that staff members checked on their welfare regularly and engaged them in discussion.

There was a wide range of activities taking place at the home. People spoke positively about these. Support for people to participate in individual activities was provided, including for people who were unable to leave their rooms.

A complaints procedure was in place which was displayed for people and relatives. People knew how to make a complaint.

Staff, residents and relatives' meetings were held regularly and surveys were completed by people and relatives. The home undertook regular monitoring of quality and safety and we saw that actions arising from these had been addressed.

The home liaised regularly with other health and social care professionals on behalf of

This inspection took place on 31 May and 1 June 2017 and was unannounced. The Highgate Care Home provides accommodation for 52 people who require nursing and personal care. On the day of our inspection there were 49 people using the service. The home was set out across four floors; of which the lower ground floor had 10 bedrooms, ground floor had 13 bedrooms, first floor had 16 bedrooms and second floor had 13 bedrooms.

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.

We last inspected this service in April and May 2015 and the service was rated as ‘Good’.

At this inspection we identified concerns with how the service managed medicines. Medicines were not being managed safely. We found five instances of where people were not administered their prescribed medicines despite nursing staff having recorded that they had. ‘As needed’ or ‘loose’ medicines were not consistently monitored to assure accurate stock levels.

People and relatives that we spoke with highlighted concerns around the low staffing levels within the home. Appropriate level of need assessments had been completed, which determined the staffing levels. We observed there to be sufficient staff available to support people.

Risks associated with people's care and support needs had been identified and these had been assessed giving staff instructions and directions on how to safely manage those risks.

People told us they felt safe. Procedures and policies relating to safeguarding people from harm were in place and accessible to staff. All staff had completed training in safeguarding adults and demonstrated an understanding of the types of abuse to look out for and how to raise safeguarding concerns.

Appropriate checks had been made to ensure the premises were safe.

We saw evidence of a comprehensive staff induction and on-going training programme. Staff had regular supervisions and annual appraisals. Staff were safely recruited with necessary pre-employment checks carried out.

People were given choices during meal times and their needs and preferences were taken into account. Nutritional assessments were in place, which included the type of food people liked and disliked. People's weight was recorded regularly and action was taken should people lose weight significantly.

The registered manager and staff demonstrated a good level of understanding of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). The registered manager had submitted applications to the local safeguarding authority for each person who required an authorisation to ensure that people were legally being deprived of their liberty which was in their best interest.

We observed caring and friendly interactions between management, staff and people who used the service and people spoke positively of staff and management.

A complaints procedure was in place which was displayed for people and relatives. There was an incident and accident procedure in place which staff knew and understood.

Staff, residents and relatives meetings were held regularly and surveys were completed by people and relatives.

People, relatives and staff spoke positively of the current management team. Quality assurance processes were in place to monitor the quality of care delivered.

We identified a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This breach related to safe medicines management. You can see what action we told the provider to take at the back of the full version of the report.

We visited the nursing home during the afternoon and evening and observed that people's care and support needs were being met calmly and efficiently. Two people who used the service told us that if they had to stay in a nursing home, they were pleased it was this one. People spoke well of the activities on offer and of the food provided. Although we saw that people's needs were being well met on the day of our visit, nearly everyone we spoke with commented that staff were very stretched at times.

The provider had improved its quality assurance checks since our last inspection and we felt that the management team was now better equipped to pick up on issues and to respond promptly. There was evidence that people were being consulted in detail about their care.

The Highgate Nursing Home is located in a well maintained, attractive building with pleasant communal areas and an attractive garden. We spoke to six people who used the service and one family carer who expressed mixed views about the care received. Three people who used the service were quite positive, one person told us 'I couldn't fault one of them [the staff members]' but the other three were more critical, particularly of care at night.

People who used the service benefitted from a range of group activities. People who could not leave their rooms due to ill health received one-to-one visits to carry out activities of interest to them. Two people spoke very highly of the music therapy sessions.

We saw evidence that staff members were, for the most part, up-to-date with mandatory training, but little dementia training had been made available, although some people who used the service had needs in this area.

We found that care was generally of good quality, but there were inconsistencies and these were not being addressed effectively.

People who use the service commented that is was “Very good”, and “Its brilliant”. They also told us that “Staff are very good, and they are very helpful” and that “There are lots of staff around and they always come quickly if you need them”.

We found that people who used the service expressed their views and were involved in making decisions about their care. People we spoke to commented that where staff assisted them with their personal care this was done in a respectful manner that reflected their preferences and promoted their dignity. We found that people’s needs were assessed and care and treatment was planned and delivered in line with their individual care plan. People we spoke to told us that they enjoyed the activities on offer and that they could choose whether or not to participate in a particular session. People who use the service told us that they enjoyed the meals provided and felt safe in the home. People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines. We found that there were enough qualified, skilled and experienced staff to meet people’s needs.

People who use the service told us that their privacy and dignity was promoted by staff, and that they were able to choose their own daily routine. A variety of daytime activities were organised within the home.

Each person using the service had an individual plan that reflected their needs and preferences, and this was regularly reviewed and updated. People using the service were supported to access a range of healthcare services.

People who use the service were protected from abuse. Appropriate pre-employment checks were carried out as part of the recruitment process. Staff appeared to be employed in sufficient numbers, and a mandatory training programme had been developed. However, we identified that some staff require training in safeguarding, tracheotomy and PEG care.

A range of measures had been developed to ensure that the quality of the service provided.

The Highgate Nursing Home can accommodate a maximum of 55 adults of all ages with a range of nursing care needs.

This inspection took place on 8 April and 5 May 2015 and was unannounced. After our first visit we gathered further feedback about the service and then made a second visit to confirm information and feedback that we had received. At our last inspection in June 2014 the service was meeting the regulations we looked at.

At the time of our inspection a registered manager was employed at the 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.

The staff of the service had access to the organisational policy and procedure for protection of adults from abuse. They also had the contact details of the London Borough of Islington which is the authority in which the service is located and other authorities who also placed people at the service. The members of staff we spoke with said that they had training about protecting adults from abuse, which we verified on training records and staff were able to describe the action they would take if a concern arose.

We found there were the designated number of staff on each floor during our visits, this helped to ensure that staff were working with people who they had come to know and could quickly identify any changes to people’s care and support needs.

We saw that risks assessments associated with people’s day to day care, for example if someone was at risk of falling, were compiled and regularly reviewed. The instructions for staff were detailed and clear and included what action should be taken to minimise these risks.

We saw there were policies, procedures and information available in relation to the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) to ensure that people who could not make decisions for themselves were protected. The service was applying MCA and DoLS safeguards appropriately and making the necessary applications for assessments when these were required.

People were supported to maintain good health. Nurses were on duty at the service 24 hours and a local GP visited the home each week, but would also attend if needed outside of these times. Staff told us they felt that healthcare needs were met effectively and this was confirmed by a local GP who regularly visited the service.

Most of the people we spoke with who either used the service, and relatives, praised staff for their caring attitudes. The care plans we looked at were based on people’s personal needs and wishes. Everyday things that were important to them were described so that staff could provide care tailored to meet their needs and wishes.

People’s views were respected as was evident from conversations that we had with people using the service, relatives, visitors and staff. We saw that staff were involved in decisions and kept updated of changes in the service and were able to feedback their views.

The service complied with the provider’s requirement to carry out regular audits of all aspects of the service. The provider carried out regular reviews of the service and sought people’s feedback on how well the service performed and outlined any the areas of improvement that were necessary to maintain the quality of the service.