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Inspection carried out on 15 May 2017

During a routine inspection

We carried out an unannounced inspection of Highlands Borders on 15 May 2017. Highlands Borders provides care and accommodation for up to 18 people who required accommodation and personal care. Nursing care can be provided through the local community nursing services if appropriate. At the time of the inspection 18 people were living at Highlands Borders.

There was a registered manager who was responsible for the home and had worked there for some time. The registered manager was on holiday at the time of the inspection so we were assisted by the 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 provider, Highlands Care Home Limited also ran another care home in Exeter and were in the process of buying a third home close by.

At this inspection we found the service was meeting all regulatory requirements and we did not identify any concerns with the care provided to people living at the home. One relative said, "It’s a lovely place, I never have to worry. I come regularly and I can join in and dance and sing with people.”

On the day of the inspection there was a calm and relaxed atmosphere in the home and we saw staff interacted with people in a friendly and respectful way. People were able to choose what they wanted to do and enjoyed spending time with the staff who were visible and attentive. There was a lot of staff interaction and engagement with people, most of whom were living with dementia and unable to tell us directly about their experiences. At the time of the inspection people were mostly relaxing, chatting and playing games in the large, airy conservatory or sitting at tables in the open plan dining area. They looked comfortable and happy to spend time in the large conservatory. People were encouraged and supported to maintain their independence. The majority of people living with dementia were independently mobile or required some assistance from one care worker. Staff engaged with them in ways which reflected people's individual needs and understanding, ensuring people mobilised safely from a discreet distance.

People were provided with good opportunities for activities, engagement and trips out. There was a sense of purpose as people engaged with staff, watched what was going on, played games and pottered around the home or spent time in their rooms. Some people were spontaneously going out with a care worker to the high street close by or for a walk. The activity co-ordinator knew people well and engaged people in activities and games which suited them. For some people with limited understanding staff used smaller items such as ‘fiddle muffs’ or sensory items to touch and interact with when there was not an organised activity planned. People could choose to take part if they wished and when some people preferred to stay in their rooms, staff checked them regularly spending one to one time with them. Most people preferred to spend time in the communal areas, including a smaller, quiet TV lounge.

People and relatives said the home was a safe place for them to live. Most people were living with a degree of dementia meaning they were not always able to tell us directly about their experience at the home. People looked happy and comfortable chatting with staff and each other. Staff knew people’s personalities and what they liked such as who liked to spend time with who. One person was able to tell us, "It’s like a hotel, I can do what I like. All the staff are really nice and there is a lovely manager. If I had a problem I could talk to them or anybody.”

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. Any safeguarding concerns had been managed well with provider involvement and the service worked with the local authority safeguarding team. For example, a recent safeguarding process had resulted in appropriate supervision and disciplinary process to ensure learning and improvement. The relative said they would speak with staff if they had any concerns and issues would be addressed. People seemed happy to go over to staff and indicate if they needed any assistance. There was a robust recruitment process, ensuring potential new staff were suitable to work with vulnerable people.

Staff were vigilant about protecting each person from possible negative interactions with other people living at the home, recognising frustrations and misunderstandings between people due to them living with dementia. They used chatting and distraction techniques as they knew people well, showing patience and understanding. For example, records showed clear documentation of any incidents such as a person raising their voice at another person. Staff showed how they discussed with one person how their behaviour may have frustrated another person. We saw staff discreetly monitoring where these people were so the incident would not re-occur.

People and relatives knew how to make a formal complaint if they needed to through the home’s complaint policy but felt that issues would usually be resolved informally. The relative said they had never had any issues but were happy to talk to any staff. We looked a recent complaint which had been well managed in a sensitive way. Improvements had been made such as monitoring room temperatures and increasing the level of communication with one person’s family. They were now able to access the computer care system with a pass code so they could feel assured their loved one was well cared for. There had been no other formal complaints.

People were well cared for and relatives were involved in planning and reviewing their care as most people were not able to be involved due to living with dementia. Care plans showed that people were enabled to make smaller day to day choices such as what drink they would like or what clothes to choose. Where people had short term memory loss staff were patient in repeating choices each time and explaining what was going on and listening to people's repeated stories. People were assisted to attend appointments with appropriate health and social care professionals to ensure they received treatment and support for their specific needs. One person’s care plan described how the person had become more nervous of the chiropodist as their dementia progressed. Staff now stayed with the person reassuring them through their treatment.

There were regular reviews of people's health, and staff responded promptly to changes in need. For example, care records showed many examples of staff identifying changes in need and appropriate and timely referrals to health professionals. Staff monitored people’s skin integrity for example. One record showed how staff had noticed a red area on one person’s foot. They had applied appropriate cream and taken a photo to aid regular monitoring. No-one at the home had any pressure sores. Other people had had assessments by the speech and language team (SALT). Health professionals could input directly into the computerised care plan system. This information was then included in an updated care plan for staff to follow. Care plans and daily records were easy to follow showing progress. Staff said, “The care plan system is fantastic. We use electronic tablets so we can record as we go. We now have more time to care and it’s easy to share any new information or changes with the team as a pop up alert too.”

Medicines were well managed and stored in line with national guidance. Records were completed with no gaps and there were regular audits of medication records and administration and to ensure the correct medication stock levels were in place.

Staff had good knowledge of people, including their needs and preferences. Care plans were individualised and comprehensive ensuring staff had up to date information in order to meet people's individual needs effectively. The home had recently completed a move from paper documents to the electronic computer care plan system. Care plans were person centred and comprehensively reflected people’s needs when we spent time with them. There was a very stable staff team who knew people really well to be able to meet their needs. Handover and communication between staff shifts was good so there was consistent care. The service rarely used agency staff but were able to fill vacancies if they could not cover shifts within the staff team.

Staff were well trained and there were good opportunities for on-going training and obtaining additional qualifications. The staff team was very stable and many care staff had worked at the home for some years. They all enjoyed working at the home and we could see they all enjoyed working as a team and spending time with the people living at the home. They were attentive and visible. They felt well supported by management and valued. The deputy manager said, “We have a good staff team. It’s so good to see where staff are going with their carers and prospects. We all believe in what we are doing and working for the people here.”

People's privacy was respected. Staff ensured people kept in touch with family and friends, inviting friends and family to outings and events regularly. The deputy manager role included public relations and they were keen that family and friends were involved as much as they wished. The relative told us they were always made welcome and were able to visit at any time. They were enjoying tea and biscuits with their loved one and joining in with the activity. People were able to see their visitors in communal areas or in private. One person said they liked quiet. This reflected what the senior care worker had told us. They continued to encourage the person to join in or take meals in the dining room but respected their wish to spend the majority of their time in their room. The senior care worker went on to describe how the person liked routine and checked on them regularly to ensure they were ok as they were reluctant to use their call bell.

The staff team and deputy manager showed great enthusiasm in wanting to provide the best level of care possible. This showed in the way they cared for people in individualised ways. During the inspection staff were very attentive. They made sure people had what they wanted to eat and drink, and made sure people’s clothes were kept clean and protected people’s dignity. They praised people when they did well in an activity and helped people feel useful. For example, one person was folding napkins and another person was ‘making notes for a stock take’. They had previously worked in an office. Staff knew what people had been doing or how they had been feeling and asked about how they were or how a trip went. The home and people’s rooms were homely and very personalised.

Observations of meal time showed this to be a positive experience, with people being supported to eat a meal of their choice where they chose to eat it. For example, two people liked eating together in the quiet lounge. Staff engaged in conversation with people and encouraged them throughout the meal, noting who liked to sit with whom. For example, they were monitoring two people who appeared to bicker but seemed happy at one table. Nutritional assessments were in place and special dietary needs were catered for as well as specialist crockery and cutlery and finger foods to aid independence for people living with dementia. The chef came up from the kitchen every lunch time to help serve up and chat to people. They left saying, “Lovely to see you all, see you tomorrow” and people waved him off. One person said, “We have a proper chef. If I don’t like the food on offer I just tell him in the morning and I get something I fancy.”

There were effective quality assurance processes in place to monitor care and plan on-going improvements. For example, monitoring any falls, risks weights and medication audits. One person was independently mobile but had had a couple of falls. Staff were working with them to encourage them to use their call bell and consider a commode in their room to minimise risk but respecting the person’s choices.

There were systems in place to share information and seek people's views about the running of the home, including relatives and stakeholders. As the home was small, there had not been a resident’s/relatives meeting for some time. One relative said they were kept well informed of everything and the registered manager had an open door policy so they did not feel meetings were needed. We could see people and relatives were able to access the manager’s office at all times as it was close to the communal area. People's views were acted upon where possible and practical, and included those living with dementia. Their views were valued and they were able to have meaningful input into the running of the home, such as activities they would like to do (a quarterly activity plan had been devised with people’s input), which mattered to them. An activity programme informed family and friends of organised events such as BBQs and trips out to the pub.

Inspection carried out on 9 February 2015

During a routine inspection

Highlands Borders Care Home is a care home which is registered to provide care for up to 17 people. The home specialises in the care of older people but does not provide nursing care . There is a manager who is responsible for the home. They had applied and were currently going through the process to apply for registration with CQC. 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 we saw 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 which were respected by staff.

People were well cared for and were involved in planning and reviewing their care or their relative was involved if they were unable to. There were regular reviews of people’s needs and staff responded promptly to changes in need. However, care records were being transferred to the new computer system which had meant that not all care records showed clear instructions to staff about how to meet people’s needs fully. For example, some instructions to staff were recorded in the daily records rather than the care plan. This meant their was a risk staff may not know about ong-oing care if this was not mentioned verbally in the shift handover .

People said the home was a safe place for them to live. Most people were living with a degree of dementia meaning they were not always able to tell us directly about their experience at the home. People looked happy and comfortable chatting with staff. One relative said the care at the home made them feel more relaxed as it was reassuring to know their relative was cared for so well. Another relative said the home was “even better than a home from home” and they had made many friends.

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.

People said they would not hesitate in speaking with staff if they had any concerns. People knew how to make a formal complaint if they needed to but felt that issues would usually be resolved informally. One relative gave an example where they had spoken to the manager about a concern which had been dealt with quickly and had not occurred again. They felt confident any issues were addressed.

People were assisted to attend appointments with appropriate health and social care professionals to ensure they received treatment and support for their specific needs.

Staff had good knowledge of people including their needs and preferences. Staff were well trained; there were good opportunities for on-going training and for obtaining additional qualifications. Comments about staff included “I congratulate the manager for running such a good establishment. The staff are excellent.” And “I have nothing but admiration for the staff at Highland Borders”.

People’s privacy was respected. Staff ensured people kept in touch with family and friends. Where people had no close family staff ensured they spent time with that person and took them out regularly. Relatives confirmed 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. One relative said “The staff make my relative feel at home. Nothing is too much trouble and they are so keen to help in any way they can”.

People were provided with a variety of activities and trips. People could choose to take part if they wished. During the inspection people were enjoying a beanbag game, going out to town and chatting with staff about music and Valentines Day. Staff at the home had been able to build strong links with the local community including regular visits to the local church, pub, shops and memory café.

There was a management structure in the home which provided clear lines of responsibility and accountability. The manager showed great enthusiasm in wanting to provide the best level of care possible. Staff had clearly adopted the same ethos and enthusiasm and this showed in the way they cared for people. One staff member was moving further away but had wished continue to work at Highlands Borders “as it’s so lovely here”. The manager had taken into account travel time when organising their shifts to make this possible. Staff said they felt valued and always enjoyed coming to work.

There were effective quality assurance processes in place to monitor care and plan on-going 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. A comment from a relative in the 2014 quality assurance survey said “We cannot believe how lucky we were to find Highland Borders. Nothing is too much trouble for the staff who are caring and most of all give people time”.