The Heights

The Heights is a nursing home. People in nursing homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission regulates both the premises and the care provided. Both were looked at during this inspection.

The Heights is registered to provide nursing and residential care for up to 90 adults with a range of needs including younger adults living with a physical or learning disability and older adults with a range of needs including dementia, epilepsy and diabetes. Younger adults had complex care needs and lived in a separate accommodation called Downley Lodge, which was adjacent to the main building. Downley Lodge had its own staff team and entrance.

At the last inspection we rated the service as outstanding. At this inspection we found that the service remained outstanding overall. The service remained outstanding in well led and had improved from good to outstanding in effective. The service the service no longer meets the criteria for outstanding in responsive and is now good in responsive.

The home 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 2008 and associated Regulations about how the service is run.

There was an extremely positive culture at the home because staff put people at the heart of their practice. Staff provided outstandingly effective care as they were highly skilled, dedicated and passionate in their approach. People received highly individualised care as staff were committed to cultivating a thorough understanding of people’s health, wellbeing needs, social histories, important relationships and preferences. Staff treated people as individuals, celebrated their life histories and enabled them to access meaningful experiences.

The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.

The registered manager encouraged and supported staff in their training and career development. Staff completed a comprehensive induction, the Care Certificate and training specific to the needs of people living in the home. The registered manager facilitated training opportunities for staff and continually reviewed their development through a supervision system. It was clear they believed in the abilities and potential of their staff as without exception, staff members told us they felt incredibly well supported. All departments of the staff team were valued and were included in daily handover meetings. This helped staff maintain a detailed oversight of people’s needs and of service developments and changes.

The chef took a collaborative approach to menu planning and held regular meetings with people and their families to ensure foods were nutritious and enjoyable. People at risk of malnutrition were provided with immediate support to maintain a healthy weight.

The home was light, spacious and extremely well decorated and contained furniture and possessions from people’s own homes as well as quiet seating areas with objects of interest. This provided attractive, appealing spaces for people and their families to relax in.

Staff were highly skilled at liaising with professionals from different agencies to provide people with timely support. They worked in partnership with professionals to ensure people received the highest possible standards of care.

Without exception, staff told us they were given support by the registered manager. Staff told us the registered manager welcomed and encouraged suggestions for improvements to the service and acted upon these to deliver excellent care. The registered manager was passionate about developing clinical knowledge to provide the best outcomes and had engaged in several research projects with local health services and universities.

Staff at the service were highly successful in integrating with the local services and organisations. They had developed good working relationships with local services including a school, nursery and supermarket and held regular fundraising events in the community. This helped people continue to remain a part of the community they had lived in prior to moving to the home.

Staff had a highly detailed understanding of the Mental Capacity Act and gave several examples of how they applied this when providing care and support to people. For those who were unable to make certain decisions, evidence showed that decisions made were in people’s best interests. People’s care plans contained detailed records of meetings held with people, their families and relevant professionals.

People and their relatives gave us positive feedback about the service provided. People told us staff were always available to them and always displayed a caring attitude. The provider ensured that there were enough staff available to meet people’s needs and uphold their wellbeing.

Through developing respectful caring bonds with people, staff learned about their personal histories, desires and ambitions and helped them to fulfil these. They saw people in terms of their positive traits and abilities and aimed to ensure they enjoyed life enhancing experiences.

People’s skills were celebrated and staff supported people to develop physical abilities whilst living at the Heights. Staff saw people’s time at the home as a phase of their life where they could grow and develop new friendships.

The registered manager was highly trained. They were a registered nurse with advanced nursing qualifications and minor illness management training. This enabled them to promptly detect and respond to changes in people’s health and refer them to the appropriate professionals such as GPs and district nurses. They shared their expertise with their staff team and ensured they completed appropriate training updates. Professionals we spoke with praised staff at the Heights for their skill, judgments and professionalism and told us that the skilled assessments completed by staff at the Heights had prevented conditions worsening in some people.

The registered manager was highly adaptable in their approach to delivering care and used technology in innovative ways to promote inclusion and reduce loneliness. They reflected on their practice and used learning to improve outcomes for people living in the home. They had developed an in-house television ‘live cast’ so those unable to leave their rooms could still feel included in activities. They had also taken part in telemedicine clinical trials and had provided feedback to local health care commissioners about this.

The service had plans in place for supporting people and meeting their needs in their last days and after their passing. Sensitive discussions were held with people regarding the place they wished to remain in in their last days and the type of treatment they preferred and needed.

We previously inspected the service on 22 May 2014. The service was meeting the requirements of the regulations at that time.

The Heights provides care for up to 90 people with a range of needs, including younger adults with learning disabilities, nursing care and care of people with dementia. Eighty three people were being cared for at the time of our visit. Younger adults had a mix of complex care needs and lived in accommodation which was separate to the main home, called Downley Lodge. This had its own entrance, facilities and staffing arrangements.

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 received positive feedback about the service. Comments from people included “I did not want to live in a care home, and found it difficult to settle…I am so happy now, I am cared for, and looked after very well,” “Staff know all their residents very well and what they like,” and “I don't think we could find a better place than this.”

People were protected from the risk of harm at the service because staff had undertaken training, to recognise and respond to safeguarding concerns. Staff had a good understanding about what safeguarding meant and how to report it.

People’s medicines were handled safely and were given to them in accordance with their prescriptions. People’s GPs and other healthcare professionals were contacted for advice whenever necessary.

There were enough staff to meet people’s needs. They were recruited using robust procedures to make sure people were supported by staff with the right skills and attributes. Staff received appropriate support through a structured induction, regular supervision and an annual appraisal of their performance. There was an on-going training programme to provide and update staff on safe ways of working. Several staff were also involved with nationally-recognised courses such as Business and Technology Education Council (BTEC) awards.

People were supported to take part in a wide range of activities. This included enabling younger adults to access the community and pursue hobbies, such as supporting the local football team.There were creative themed displays around the building to help engage with people with dementia and to reminisce. Staff had gone above and beyond the call of duty to fulfil some people’s wishes and dreams.

The building was well maintained and kept in a safe condition. Evacuation plans had been written for each person, to help support them safely in the event of an emergency.

The registered manager took part in various accreditation and research schemes to help improve the quality of people’s care. There were clear visions and values for how the service should operate and staff promoted these.

The provider regularly checked quality of care at the service through visits and audits. These showed the service was performing well. Records were maintained to a good standard and staff had access to policies and procedures to guide their practice.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask:

' Is the service caring?

' Is the service responsive?

' Is the service safe?

' Is the service effective?

' Is the service well-led?

This is a summary of what we found -

Is the service safe?

We found there were effective systems in place to reduce the risk and spread of infection. We saw improvements had been made to infection control practice at the home. This included use of wheeled trolleys to transport clinical and other waste out of the building. This reduced the likelihood of contaminated waste coming into contact with floors and other surfaces. Training had taken place so that more staff had the necessary skills and knowledge about good infection control practices. We saw waste bags were sealed with plastic ties to prevent the contents spilling and spreading infection. We noted covered trolleys were in use to control hazards associated with soiled or contaminated laundry and reduce the risk of infection.

People we spoke with told us the home was kept clean. One person said 'It's always kept nice and clean,' another said 'Someone comes and cleans my room every day.' Housekeeping staff told us they were provided with the materials they needed to carry out their work effectively. They said they were informed when people had infections, such as MRSA, and described the precautions taken to prevent cross infection. This showed staff followed appropriate guidance in relation to infection control practice.

People who used the service were only deprived of their liberty when this had been authorised by the Court of Protection, or by a Supervisory Body under the Deprivation of Liberty Safeguards (DoLS). We read documents which related to a recent authorisation by the local authority. This showed the service had made an appropriate referral where someone wanted to return to their former home. The manager told us training was being arranged for staff, to provide them with the skills and knowledge to understand about mental capacity and DoLS.

Improvements had been made to medication practice. This included completion of training by all staff who handled medicines, better safeguards on the use of 'as required' medications and daily audits of controlled drugs. This ensured medicines were handled safely and appropriately at the home.

We looked at a range of records as part of this visit, including care plans, risk assessments, training records and medication administration records. We found improvements had been made at the home to ensure records were up to date, well maintained and fit for purpose. The manager was able to locate all records we requested promptly. Sensitive information, such as staff files, was kept securely with access restricted to authorised persons only. This ensured confidential information was stored safely and appropriately.

Is the service effective?

We looked at a sample of care plans and other records in two different parts of the building. These showed that people's needs were assessed and care and treatment was planned and delivered in line with their individual care plan. Each care plan provided a comprehensive account of the person's needs and how these were to be met. Information had been kept up to date and reviewed regularly. This ensured changes to people's circumstances were identified promptly and their care amended as necessary.

Is the service caring?

Two visitors we spoke with were pleased with the overall standards of care. One told us their relative was 'Well cared for and happy here. Staff look after him and they call the doctor if they're worried.' We spoke with six people and observed care where people could not express their views to us. People were generally satisfied with their care. Comments included 'There's a good range of activities. I like to go to all of them,' 'Staff are friendly and respectful. They have a laugh with me,' 'My family can come any time and they're made welcome,' and 'I'm settled and well looked after. The food is good and there's always lots of vegetables, which I like.'

We observed staff were mostly attentive to people and provided reassurance where people showed signs of distress. We overheard one incident where a member of staff spoke harshly to a person. When we mentioned this to the manager, action was taken straight away to look into what happened and prevent recurrence.

Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. Risk assessments had been written for a range of activities and situations. For example, use of bed rails, the likelihood of developing pressure damage, risk of malnutrition and assisting people with moving and handling. These assessments had been kept up to date and information was reviewed on a regular basis. Support plans were put in place where people were assessed as being at risk. This helped reduce or control the potential for people to experience harm.

Is the service responsive?

Records showed people had access to healthcare professionals and specialist advice, such as Parkinson's Disease nurses and tissue viability nurses. Staff kept records of the outcome of any medical visits or appointments people had. These provided an account of any recommended courses of treatment and follow up action required. We saw staff were prepared for the GP's round on the day of our visit. For example, the relevant care plans and medication records were to hand for the doctor to refer to. Staff were able to answer any questions the doctor had about people's health and updated them accordingly. The doctor described how they worked collaboratively with the home to meet people's healthcare needs and said they had been impressed by some of the staff. They said they did not have any concerns about people's care and welfare.

Is the service well-led?

The provider had a system of carrying out annual quality assurance audits of its services and themed audits throughout the year. Regular monitoring visits were made by the home's line manager, who was the divisional nursing lead for the organisation. Areas which needed improvement were identified as part of these processes and actions were taken to remedy matters.

There was an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who used the service and others. Risk assessments were in place, such as personal emergency evacuation plans, moving and handling assessments and nutritional screening. These had been kept under regular review to ensure information was correct and reflected people's changing needs.

We were satisfied the provider had made sufficient improvements in the areas where we previously had concerns and was now compliant.

People told us the staff were 'lovely' with one person telling us 'they are good staff here, they come to help me when I need it.' A relative told us 'it's the best it can be if they need to be in somewhere.'

We found not all people who lived there were receiving the care and support they required to meet their needs.

People were safe from abuse as the staff were aware of the signs to look for and people told us they would report any issues they had.

Relatives told us the home was 'always clean.' We saw there were some practices which meant people may be at risk from the spread of infection.

People received their prescribed medicines.

Some people who lived at the home and their relatives told us there were not always enough staff to meet people's needs. We found this was under review by the organisation.

Staff we spoke with told us they felt supported by their manager.

People who lived there and their relatives knew how to complain. Where complaints had been made these had been investigated and measures taken to prevent recurrence.

The records regarding assessments of people's risks, needs and how to meet them did not provide sufficient information for staff. Records of staff training were not up to date.