All inspections: Highfield Manor Care Home

This inspection took place on 23 and 24 August 2016 and was unannounced. This comprehensive inspection was carried out to review progress on meeting the regulations and shortfalls identified at previous inspections and to review the rating.

We last inspected Highfield Manor Care Home in April 2016. At this focused inspection we identified some improvement but we also found repeated shortfalls and breaches of the regulations. The home received an overall rating of Inadequate at the July 2015 and January 2016 inspections. The rating was not changed at the inspection in April 2016. This was because although there had been some improvements found at that inspection we did not have evidence that these had been sustained or embedded to enable us to change the ratings given.

Highfield Manor is registered to provide personal care for up to 46 people living with dementia. Nursing care is not provided. At this inspection there were 18 people living at the home.

There was not a registered manager at the home. 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 previous registered manager, who is also a director of the registered provider, cancelled their registration in August 2015. A management consultancy was appointed in January 2016 to oversee and manage the home until a new manager was registered. The new manager was appointed in May 2016 and has applied to be registered. They have been working alongside the management consultants who will continue to be responsible for the care provision at the home. The provider remains responsible for the ongoing purchasing, maintenance and safety of equipment and of the building.

For ease of reference we have referred to the new manager and management consultants as the ‘management team’ throughout the report.

At the comprehensive inspection in July 2015 the provider was placed into special measures by CQC. In addition to placing the service in special measures in July 2015 we imposed an urgent condition on the provider’s registration. This means further people cannot move into the home or return from hospital without agreement by CQC.

At the January and April 2016 inspections we found that there was not enough improvement in the service to take the provider out of special measures. At this inspection we identified improvements particularly in people’s experiences and the care they received from staff. However, due to the continued repeated breaches of the regulations relating to the safety of people, equipment and buildings we have rated the ‘Is this service Safe’ question as inadequate. This means although the service has made improvements and has an overall rating of ‘Requires Improvement’ the home remains in special measures. This is because the service has been rated Inadequate in any key question over two consecutive comprehensive inspections. For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

We have requested the provider send us an action plan every month to tell us what action they have taken to meet all of the shortfalls identified at the previous inspections. Since April 2016 these have been provided by the management team. These action plans included information about the improvements we found at this inspection and progress on meeting the regulations.

At this inspection, people’s medicines were not consistently safely managed or stored. This was because medicines were not stored at a safe temperature and some specialist medicines were not recorded as required. One specialist medicine was out of date and the checking in medicine audit systems had not identified the shortfalls. The management team took action to address the medicines shortfalls.

There were fire safety shortfalls that had not been addressed by the provider when they were first identified. Following this inspection the provider arranged for the repairs to the emergency lighting to be made. In addition, action had not been taken in response to the works needed following a legionella risk assessment in 2015.

There was only one assisted bathroom out of four that was safe to use. There were some communal areas where the call bells were not working. Some carpets in communal areas were heavily stained and needed cleaning. Some areas of the home were very hot. This was first identified in July 2015 and there continued to be shortfalls in making suitable arrangements for safely cooling the home.

The shortfalls in the medicines management and ensuring the premises and equipment were safe for people, the cleanliness of some communal carpets, the high temperatures and the lack of ensuring equipment and the premises are properly maintained were breaches in the regulations.

The principles of the Mental Capacity Act 2005 were not consistently adhered to. This was because there were continued shortfalls in the recording of people’s consent, mental capacity assessments and decisions made in people’s best interests. Following the inspection the management team took action to address this repeated breach in the regulations. However, we have not yet been able to determine whether this action has been sufficient to meet the regulation.

Improvements had been made to the signage in the home but the building décor still was not suitable for people living with dementia and did not take into account national good practice such as that produced by the University of Stirling. There was a plan in place produced by the management consultants. However, the works and funding required were the responsibility of the provider. This remains an area for improvement.

The delays and lack of action by the provider to address and mitigate the risks to people and others and improve on shortfalls identified were also a breach of the regulations.

People and relatives told us they were safe and one person told us they now felt safe when they previously had not. People and relatives spoke highly of the caring qualities of staff and we observed positive and caring interactions from staff.

There were enough staff to meet people’s needs and this had a positive impact on people and the staff team. Staff were recruited safely. Staff were supported in their roles through training and supervision. Morale was good and staff recognised that they had worked hard under the guidance of the current management team to bring about the changes that were needed.

We found significant improvements in people’s experiences, the care and support they received and their wellbeing. People’s mealtime experiences were improved and there were enough staff to sit with and support people to eat in a relaxed atmosphere.

People’s individual care needs were met by staff who knew them well and were familiar with the care they needed. People had access to the healthcare they needed. There was an activities coordinator and there was a range of activities for people that was based on their preferences.

People’s needs were reassessed when their circumstances changed and care plans were updated and included all the information staff needed to be able to care for people.

People’s privacy and dignity was maintained and staff were respectful and caring towards people. People could receive visitors whenever they wished.

There was a caring, open culture. People, relatives and staff were kept informed of developments at the home and were consulted regarding how the home was run. There were regular meetings for relatives and staff. Staff felt well supported by the management team.

A quality assurance system was being introduced. The management team audited and reported back on various aspects of the running of the home. These fed in to an improvement plan. Actions had been taken by the management team, and improvements had been made to meet most of the regulations they were responsible for. We were not able to tell whether the improvements we found could be successfully embedded and sustained. We will review the impact of these improvements further at our next inspection.

Following previous inspections we considered the appropriate regulatory response to our findings of repeated shortfalls. We have taken action in response to these failings and have cancelled the providers registration with CQC.

This inspection took place on 13, 14, 15 and 18 January 2016 was unannounced. The inspection was carried out in response to concerns received, and changes in the management arrangements at the home.

We last inspected Highfield Manor Care Home in July 2015 and we identified serious shortfalls and breaches of the regulations. The home received an overall rating of Inadequate at that inspection.

Highfield Manor is registered to provide personal care for up to 46 people living with dementia. Nursing care is not provided. There were 27 people living at the home at the time of the inspection.

There was not a registered manager at the home. One of the deputy managers was acting as interim manager. In addition there was a newly appointed prospective service manager who was considering whether to apply to be registered. The previous registered manager, who was also a director of the registered provider, cancelled their registration in August 2015. They have continued to have a daily presence in the home. A manager had been appointed in September 2015 but they did not register and they left the home in January 2016.

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.

At the last comprehensive inspection in July 2015 this provider was placed into special measures by CQC. At this inspection we found that there was not enough improvement in the service to take the provider out of special measures.

In addition to placing the service in special measures in July 2015 we imposed an urgent condition on the provider’s registration. This means further people cannot move into the home or return from hospital without our agreement. This was because people’s care was not assessed, planned for and was not provided in a safe way. People’s nutritional needs were not met and this placed them at risk of harm.

We have requested the provider send us an action plan every month to tell us what action they have taken to meet all of the shortfalls identified at the July 2015 inspection.

At this inspection we identified continued serious shortfalls and 10 repeated and three new breaches of the regulations. The service met the previous breach of the regulations in relation to recruitment of staff recruitment. Some improvements were seen in the support and training staff received.

We identified safeguarding concerns during the inspection and raised three safeguarding alerts with the local authority, who are responsible for investigating any allegations of abuse.

CQC is now considering the appropriate regulatory response to the shortfalls we found. Where providers are not meeting the fundamental standards, we have a range of enforcement powers we can use to protect the health, safety and welfare of people who use this service (and others, where appropriate). When we propose to take enforcement action, our decision is open to challenge by the provider through a variety of internal and external appeal processes. We will publish a further report on any action we take.

Any risks to people’s safety were not consistently assessed and managed to minimise risks. For example, plans and the support were not in place to manage the risk for people who had multiple falls and sustained injuries, and those people who needed support to mobilise safely or to be moved using equipment such as hoists. These shortfalls were repeated breaches of the regulations.

People’s needs were not reassessed when their circumstances changed and care plans were not updated or did not include all the information staff needed to be able to care for people. Staff did not consistently follow care plans. People did not always receive the supervision, care and treatment they needed and this placed them at risk. People particularly at risk were those people living with dementia, those who were nutritionally at risk, and those with complex physical care needs. Some people’s health care needs such as pressure area care, pain management and dental and foot care were not always met because the healthcare support they needed was not delivered. These shortfalls were repeated breaches of the regulations.

A small number of people were not always treated with respect and their dignity was not maintained. This was a repeated breach of the regulations. Overall, staff were caring and were respectful in the way they treated and spoke with people.

People’s medicines were not always safely managed or administered. This was because staff did not have clear instructions when they needed to give some people ‘as needed’ medicines. Some people may have received ‘as needed’ sedative medicines when they did not need it. This was because the reasons for administration had not been recorded for some ‘as needed’ medicines. The shortfalls in medicines management was a repeated breach of the regulations. Medicines were stored safely.

People’s mealtime experiences were improved from the last inspection. However, some people did not all receive the monitoring, support and fortified fluids and food they needed to increase or maintain their weight. This was a repeated breach of the regulations.

There were not consistently enough staff to meet people’s needs. This was because some people at the home needed two or three staff to safely care for them. This was repeated breach of the regulations.

Staff did not know enough about people as individuals to be able to provide personalised care.

Some people who were cared for in their bedrooms did not have anything to occupy or stimulate them that was based on their individual needs and preferences.

Some people living with dementia were not able to find their way around the building. The building was not suitable for people living with dementia and did not take into account national good practice. This was a repeated breach of the regulations.

Staff still did not fully understand or adhere to the principles of the Mental Capacity act 2005. This was a repeated breach of the regulations.

Some people were being deprived of their liberty and had Deprivation of Liberty Safeguards (DoLS) applications or authorisations in place. Some people’s conditions in relation to their authorisations were not being met and one person was being deprived of their liberty unlawfully. This was new breach of the regulations.

Complaints information was not displayed and there was no consistent system for investigating, managing and responding to complaints. This was a repeated breach of the regulations

We were not notified about allegations of abuse at the home, some actions from safeguarding meetings were not completed and learning and outcomes were not shared with staff. This was a repeated breach of the regulations.

The provider had not notified us of all of the significant events that had happened at the home. This was a new breach of the regulations.

The home’s inspection rating was not displayed and a copy of the report was not made available to people and visitors. This was a new breach of the regulations.

The home was not well-led. The management consultant told us they were not able to fully manage the service. The provider had been providing us with a monthly action plan as to how they were going to meet the regulations. This and other information provided to CQC was inconsistent and was contradictory to the findings of the inspection.

There were some improvements in the overall care that people were receiving. However, the management of the home was still reactive rather than proactive. When we identified shortfalls, safeguarding concerns and risks to people they were addressed. New management consultants were appointed during the inspection.

The systems in place for assessing and monitoring the quality and safety of the service were still not effective. This was because the shortfalls we found had not been identified by the service.

Record keeping had improved but there were still shortfalls in the accuracy of records kept about people.

The shortfalls in the governance of the home were a repeated breach of the regulations.

Staff were warm, friendly and caring towards people. Staff smiled with people and gave them time to say what they wanted to. They spoke about people with a genuine fondness and they were concerned about their general wellbeing. Staff told us they believed people were now getting good quality care.

People enjoyed the individual and group activities provided in the main lounges by the activities workers and care staff.

Staff recruitment practices were safe and relevant checks had been completed before staff worked with people. Some staff told us they had attended training since the last inspection. Staff felt better supported and they had formal one to one supports meeting. Some staff had received an annual appraisal to review their performance. However, this was not consistent across the staff team and this was an area for improvement.

This inspection took place on 19 and 20 April 2016 was unannounced. This focused inspection was carried out to review the progress on meeting the regulations and shortfalls identified at previous inspections .

We last inspected Highfield Manor Care Home in Jan 2016 and we identified repeated shortfalls and breaches of the regulations. The home received an overall rating of Inadequate at that and the July 2015 inspection. Whilst there had been some improvements found at this inspection we did not have evidence that these had been sustained or embedded to enable us to change the ratings given at the last comprehensive inspection.

Highfield Manor is registered to provide personal care for up to 46 people living with dementia. Nursing care is not provided. At the start of the inspection were 23 people living at the home at the time of the inspection. Three people moved out during the inspection.

There was not a registered manager at the home. The previous registered manager, who is also a director of the registered provider, cancelled their registration in August 2015. A management consultancy was appointed in January 2016 to oversee and manage the home until a new manager is appointed. Two of the management consultants were acting as interim 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.

At the comprehensive inspection in July 2015 this provider was placed into special measures by CQC. At the January 2016 inspection we found that there was not enough improvement in the service to take the provider out of special measures. This inspection was to review progress on the breaches of the regulations. The home remains in special measures.

In addition to placing the service in special measures in July 2015 we imposed an urgent condition on the provider’s registration. This means further people cannot move into the home or return from hospital without our agreement. This was because people’s care was not assessed, planned for and was not provided in a safe way. People’s nutritional needs were not met and this placed them at risk of harm.

We have requested the provider send us an action plan every month to tell us what action they have taken to meet all of the shortfalls identified at the July 2015 and January 2016 inspections.

At this inspection we identified continued shortfalls and six repeated breaches of the regulations. The service had improved and met the regulations in relation to people’s privacy and dignity and their nutrition. The complaint procedure was now displayed. The service’s rating was displayed and we had been notified about incidents as required by the regulations.

CQC is now considering the appropriate regulatory response to the shortfalls we found. Where providers are not meeting the fundamental standards, we have a range of enforcement powers we can use to protect the health, safety and welfare of people who use this service (and others, where appropriate). When we propose to take enforcement action, our decision is open to challenge by the provider through a variety of internal and external appeal processes. We will publish a further report on any action we take.

There were some improvements in the risk management of individuals. However, some risks to people’s safety were not consistently assessed and managed to minimise risks. For example, plans and the support were not in place to manage the risk for people who needed to be moved using equipment such as hoists and staff did not have access to the correct information about people and how to manage some risks.

People’s medicines were not consistently safely managed or administered. This was because staff did not have clear instructions when they needed to give some people ‘as needed’ medicines. Some medicines plans and records did not include the correct information and this potentially placed people at risk of having medicines they no longer needed them or at the wrong time. The shortfalls in the people’s risk and medicines management were a repeated breach of the regulations.

Some people’s needs were not reassessed when their circumstances changed and care plans were not updated or did not include all the information staff needed to be able to care for people. Some care plans included contradictory information. Staff did not consistently follow care plans to deliver the care people needed. This meant people were at risk of not receiving the care they needed.

Staffing levels had been increased at night and there were plans to increase the staffing during the day. However, there were not consistently enough staff to meet some people’s needs who were accommodated in the basement and the first floor particularly at mealtimes. This meant some people did not all receive the support they needed to eat at a dining table or at the same time as other people. Following the inspection the management consultants informed us the staffing had been increased. Most staff had not received the training they needed to be able to meet the needs of people living with dementia. These shortfalls were a repeated breach of the regulations.

Although some improvements had been made to the signage in the home, the building still was not suitable for people living with dementia and did not take into account national good practice such as that produced by the University of Stirling. There was a plan in place produced by the management consultants. However, because action had not been taken to fully address the suitability of the home since October 2014 this was a repeated breach of the regulations.

Staff still did not fully understand or adhere to the principles of the Mental Capacity Act 2005. This was because there were continued shortfalls in some staff’s understanding and recording of people’s consent, mental capacity assessments and decisions made in people’s best interests. This was a repeated breach of the regulations.

The management consultants had made some improvements at the home. Relatives and staff told us they were open and approachable. However, there were still repeated shortfalls in the quality and safety of the service and any improvements had not been embedded to ensure the service met the regulations. The shortfalls in the governance of the home were a repeated breach of the regulations.

Some people were being deprived of their liberty and had Deprivation of Liberty Safeguards (DoLS) applications or authorisations in place. People’s conditions in relation to their authorisations were being met. This was an improvement.

Some people’s mealtime experiences were much improved from the last inspection. They were a social occasion for some people and staff supported people sensitively.

Some staff knew about people as individuals so they could provide personalised care. This was an improvement but this was not consistent across the staff team. Some people who were cared for in their bedrooms did have music playing but not all of these people had something to occupy or stimulate them that was based on their individual needs and preferences.

People were occupied during the inspection and actively engaged with staff. Staff were kind and responsive to people’s needs. People and staff smiled and laughed with each other. They enjoyed doing activities together.

The management consultants were leading by example and provided guidance and support to staff so they could appropriately support people living with dementia.

Complaints information was now displayed and there was a system for investigating, managing and responding to complaints.

This inspection took place on 13, 14 and 16 July 2015 was unannounced. The inspection was carried out in response to safeguarding concerns.

We last inspected Highfield Manor Care Home in March 2015 and we did not identify any breaches in the regulations.

Highfield Manor is registered to provide personal care for up to 46 people living with dementia. Nursing care is not provided. There were 38 people living at the home at the time of the inspection. The registered manager, who was also a director of the registered provider, was not working in the home at the time of the inspection. 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.

At this inspection we identified serious shortfalls and breaches of the regulations. You can see some of the action we have taken at the end of this report.

We identified serious safeguarding concerns during the inspection and raised multiple safeguarding alerts with the local authority, who are responsible for investigating any allegations of abuse.

Where providers are not meeting the fundamental standards, we have a range of enforcement powers we can use to protect the health, safety and welfare of people who use this service (and others, where appropriate). When we propose to take enforcement action, our decision is open to challenge by the provider through a variety of internal and external appeal processes. We will publish a further report on any action we take.

People’s needs were not fully assessed by staff working at the home before they moved in. This meant care plans were not developed until the person was already at the home. This placed them of risk of not having their needs met when they moved in.

Risks to people were not fully assessed and management plans were not always in place to minimise these risks. For example, plans and the support were not in place to manage the risk for people who had epilepsy, people who had multiple falls and sustained injuries, and those people who need support to mobilise safely.

People did not always receive the care and support they needed and this placed them at risk of harm or neglect. Their health and care needs were not always met because the care and support they needed was not delivered. People who were living with dementia who were unable to express their views, those who had vulnerable skin, had complex mental health conditions, or had lost weight,or needed end of life care were particularly at risk. Action was not consistently taken when people sustained injuries or they were unwell. People’s pain was not assessed to make sure people received adequate pain relief.

Staff did not know enough about people as individuals to be able to provide personalised care. Some people who were cared for in their bedrooms and in the lower basement did not have anything to occupy them that was based on their individual needs and preferences.

People were not supported to eat and drink in safe, respectful and dignified way. People were not informed what they were eating, they were not given choices and people were supported to eat by having cutlery tapped or cutlery pushed on their mouths without any conversation or waiting until they opened their eyes. Staff did not give people food and fluids in line with their specialist diets and this placed them at risk of choking and the risk of food or fluids entering their lungs. Some people who were losing weight did not have their food and fluids effectively monitored to make sure they were eating and drinking enough.

Not all of the staff were caring in their approach to people. Some staff did not smile at people or reassure them when they were upset or worried about things. However, staff who had worked at the home for a number of months spoke fondly of the people they supported and cared for. Most of these staff were warm and friendly in their approach to people.

Some people’s medicines were not safely managed, recorded or administered. This was because one person’s medicines were stopped by the staff at the home without the agreement of the GP, other people’s creams were not applied as prescribed and some records were not accurate.

The systems for keeping people safe from abuse were not effective and this placed people at risk of harm and abuse. Not all staff had been trained and not all would report allegations of abuse. We identified two allegations of abuse that had not been reported to the local authority and CQC. No action had been taken in response to one of these allegations.

The service was not fully meeting the requirements of the Mental Capacity Act 2005. Staff were not fully aware of the principles of the Mental Capacity Act 2005, making best interest decisions. They did not know which people were being deprived of their liberty and who had Deprivation of Liberty Safeguards (DoLS) applications or authorisations in place.

Other risks to people in the home were not managed. There were not any means of cooling some areas of the building and action was not taken to repair a fire door that was off its hinge for thirteen days. There was an unpleasant smell in the lowered basement where people sat and ate their meals. The building was not suitable for people living with dementia and did not take into account national good practice. Some people’s evacuation plans for the emergency services were not up to date.

There were not enough staff to meet people’s needs on the first day of the inspection. There was not any way of assessing how many staff they needed to meet people’s needs. Staffing levels were increased following us feeding back our serious concerns at the end of the first day.

Most staff did not have the knowledge, experience or communication skills to be able to understand and communicate effectively with people who were living with dementia. Staff were not recruited safely, they did not receive any formal support sessions and they did not all have the training they needed to be able to meet people’s needs.

Overall, people told us and during the inspection we saw that staff responded quickly to call bells. However, three people did not have access to a call bell, including one person who was receiving end of life care. There was no call bell in their bedroom for staff to call for assistance.

The home was not well-led and there were no clear management arrangements in place at the home. There was not an open and transparent culture at the home. The findings throughout the inspection showed there was a failure to assess, monitor and mitigate the risks relating to the health, safety and welfare of people and others who may be at risk. In addition, there was a failure to assess, monitor and improve the quality and safety of the services provided. The systems in place had not identified the shortfalls we found for people or driven improvement in the quality of care or service provided.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

Services placed in special measures will be inspected again within six months. The service will be kept under review and if needed could be escalated to urgent enforcement action.

This inspection took place on 16 and 17 March 2015 and was unannounced. The aim of the inspection was to carry out a full comprehensive review of the service and to follow-up on the six compliance actions made at the previous inspections carried out on 1, 2 and 15 October 2014 and 8 January 2015.

People living at the home felt safe. For example one person told us, ““The staff know what’s wanted; they’re alright, they wouldn’t hurt you”. Relatives overall were also generally positive about the care provided at the home.

Medicines were managed safely in the home. People had their medicines administered as prescribed and staff had been trained in safe medication administration. There was less use of ‘as required’ medicines that we had found on previous inspections to be over used. Care plans gave guidance to staff on when it was appropriate to use these ‘as required medicines’. Pain assessment tools were now being used for people who could not inform staff that they were in pain. There were suitable storage facilities for storing medicines.

Since the last inspection the safeguarding procedure had been updated as required and staff were trained and knowledgeable about how to raise concerns appropriately.

We also found that there was better risk management to keep people safe. Bed rail risk assessments were now in place and each person had a personal evacuation plan.

There was improvement in record keeping. At the last inspection we identified that some records were out of date or had not been completed. At this inspection records were up to date and accurate.

At the last inspection we had found there were not enough staff to meet people’s needs. At this inspection people, relatives and staff all said that the staffing levels were appropriate. There were less people accommodated at this inspection and we saw evidence of staffing levels being increased if there was an increased need. The acting manager agreed that a dependency tool would be used in future to better inform the assessment of staffing requirements.

There were robust recruitment procedures being followed to make sure suitable staff were employed to work at the home.

Overall, at this inspection the home was more effective in meeting people’s needs. Part of this had been brought about as better training in core subjects had been provided. For example, moving and handling training and dementia care.

At the last inspection we found staff were not receiving adequate supervision. Action had been taken at this inspection to address this.

At the last inspection the requirements of the Mental Capacity Act 2005 were not being carried out, with particular reference to making ‘best interest’ decisions on behalf of people who lacked capacity. At this inspection we found the home was now compliant with better records and assessments to evidence this.

There was also an improvement at this inspection with regards to food provided. Drinks and snacks were now available to people throughout the day. Visual prompts to assist people living with dementia in choosing meals had been adopted and the home had sought advice about improving menus and overall nutrition. Where people were at risk of not having enough to drink, there was better monitoring and care planning to make sure people did not become dehydrated. People were weighed regularly and action taken if people lost weight.

Improvements could still be made to make the physical environment more suitable for people living with dementia.

People and relatives were positive about the care staff and how people were looked after and supported.

Management had made sure that changes in staff practice of getting people up early, washing and dressing them and putting them back to bed had ceased.

More activities were being provided and this should improve further when the new activities coordinator starts work at the home.

At this inspection we found an improvement in care planning. Care plans were up to date and reflected the needs of people whose care we focused on. New format care plans were being developed.

Action had been taken to make the complaints system more effective. The procedure had been updated and was prominently displayed in the reception area. Complaints had been investigated and there was monthly auditing to make sure that lessons could be learnt.

At this inspection we found there was more openness and transparency in how the home was managed. Staff and relatives said they were comfortable with the management and felt that they were listened to.

There were better systems in place to monitor the quality of service provided.

We carried out an unannounced comprehensive inspection of this service on 1, 2 and 15 October 2014. Breaches of legal requirements were found and we issued a warning notice for breaches in medicines management. The provider was required to meet the regulation by 14 November 2014.

As a result we undertook an unannounced focused inspection on 22 December 2014 to follow up on whether action had been taken to deal with the breach.

Following the receipt of further adult safeguarding concerns about Highfield Manor Care Home we carried out an unannounced inspection at 5.40 am on 8 January 2015.

You can read a summary of our findings from the three inspections below.

Comprehensive Inspection of 1, 2 and 15 October 2014

This was an unannounced inspection on 1, 2 and 15 October 2014.

Highfield Manor is registered to provide personal care for up to 46 people living with dementia. Nursing care is not provided. There were 45 people living at the home when inspected. The registered manager is also one of the directors of the provider RYSA Highfield Manor Limited. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.

There were unsafe arrangements for the management and administration of medicines that put people at risk of harm. People were given sedative medicines routinely rather than when needed them and as prescribed by their GP. These people were subject to sedation at times when they did not need it and this placed them at risk of harm.

Policies about keeping people safe and reporting allegations of abuse were out of date and one member of staff was not sure how they should respond to abuse.

Any risks to people’s safety were not consistently assessed and managed to minimise risks. For example, behaviours that may challenge others and emergencies had not been risk assessed and planned for so staff knew what action to take. People’s needs were not reassessed when their circumstances changed and care plans were not updated or did not include all the information staff needed to be able to care for people. This meant that for some people prompt action or referrals were not made to the right healthcare professionals and they did not receive the care they needed. People’s need for social stimulation, occupation and activities were not consistently met.

People’s care and monitoring records were not consistently maintained and we could not be sure they accurately reflected the care and support provided to people.

Staff did not have the right skills and knowledge to provide personalised care for people living with dementia. This was because they did not have a full induction into care, the right training or regular support and developments sessions with their managers.

Staff did not fully understand about the Mental Capacity Act 2005, and how to assess people’s capacity to make specific decisions or about those people who were being restricted under Deprivation of Liberties Safeguards. This meant that some people may have been unlawfully deprived of their liberty or had restrictions place on them.

Some people had lost weight and prompt action had not been taken to ensure they had high calorie and high fat foods such as cream to increase their weight. Food and fluid plans were not in place for people who were at risk of losing weight so that staff knew what action to take to support them.

Information about making complaints was not displayed and contact information was incorrect. There were mixed views from relatives about whether they felt able to complain about the home.

The systems in place and the culture at the home did not ensure the service was well-led. This was because people were not encouraged to be involved in the home. People were not consulted, staff were not consulted and the quality assurance systems in place did not identify shortfalls in the service. The service did not have effective systems in place to ensure it was well led and people received a good service.

There were enough staff on duty during the inspection to meet people’s needs and staff were recruited safely to make sure they were suitable to work with people. There were staff meetings and handovers to share information between staff.

Staff were caring and treated people with dignity and respect. Staff knew people’s basic care needs and some personal information about them. We saw good relationships and interactions between some staff and people.

At our last inspection in November 2013 we did not identify any concerns.

Focused inspection of 22 December 2014

After our inspections of 1, 2 and 15 October 2014 the provider was served a warning notice in relation to medicines management. This required the service to be compliant by 14 November 2014. We undertook this unannounced focused inspection to check that the breach of the regulations had been addressed.

The provider had developed a plan to address the shortfalls with an independent pharmacist appointed by the local authority. The independent pharmacist was appointed because of the concerns relating to medicines management. We found that the provider had followed their plan in relation to meeting this regulation. However, medicines were not stored at their recommended temperatures and appropriate actions had not been taken when this was identified by staff. This was an area for improvement because the incorrect fridge temperatures could affect the effectiveness of people’s medicines.

People’s medicines had been reviewed by their GPs. Following these reviews the prescribing, dispensing and Medication Administration Records (MAR) were being updated to reflect these changes. Care plans were in place for people who were prescribed ‘as needed’ medicines with supporting information on “how I take my medicines”. ‘As needed’ sedative medicines prescribed were administered infrequently. Staff managing medicines for people had been trained and their ability to safely administer medicines was monitored.

We will undertake another unannounced inspection to check on all other outstanding legal breaches identified for this home.

Focused inspection 8 January 2015

We inspected the home unannounced at 5.40 am in response to concerns being raised about the staffing levels, staff recruitment and care practices. The provider had not yet been required to submit an action plan as to how they were going to meet the breaches of the regulations we identified at our previous inspection. This meant we were not yet able to check the actions they had taken to meet the breaches identified at the October 2014 inspection.

We found two repeated and two new breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. These breaches were in relation to respecting people’s dignity and choices, staffing, record keeping and assessing and monitoring the quality and safety of the service. You can see what action we told the provider to take at the back of the full version of this report.

We were unable to gain entry into the home until 6.15am because staff did not have access to the telephone and external entrance intercom. This was an area for improvement because staff were not able to respond to the telephone or make emergency calls if they needed to.

There were not enough staff on duty at all times to meet the needs of the people living at the home. This was because some of the 45 people who were living with dementia needed two staff to support them with their mobility and personal care. One of the staff members was appointed to work with one person at all times and should not have been included in the overall staffing levels.

At our inspection in October 2014 we identified that records were not accurate and this placed people at risk of unsafe or inappropriate care. At this inspection records did not reflect that some people had been dressed and returned to bed or sat in their armchair. Records also did not statewhen assessments had been completed or how any injuries had been sustained. This was a continuing breach of the regulations in relation to records.

At 6.15 nine of the 45 people were dressed in their day clothes and were asleep either in bed or in an armchair. All of these people were living with dementia and some may not have been able to determine what the time was when they were dressed by staff. People being dressed and put back to bed was not dignified and did not respect people or their choices about when they liked to get up.

There were not robust systems in place to determine and assess whether people’s needs could be met and whether there was sufficient staff to meet their needs prior to them moving in the home. This was an area for improvement identified in October 2014 and at this inspection.

At our inspection in October 2014 we identified there were not effective systems in place to ensure people received a good and safe service. The registered manager was not at work and the three deputy managers were covering the absence. They had been able to cover the day to day management of the home and action the immediate concerns about medicines management. However, they had not had time to undertake some of the quality monitoring such as auditing accidents and incidents for any trends. This was a continuing breach of the regulation in relation to assessing and monitoring the quality and safety of the service.

Staff were recruited safely and checks on their suitability to work with people had been made.

We will undertake another unannounced inspection to check on the new and other outstanding legal breaches identified for this home.

We carried out an unannounced comprehensive inspection of this service on 1, 2 and 15 October 2014. Breaches of legal requirements were found and we issued a warning notice for breaches in medicines management. The provider was required to meet the regulation by 14 November 2014.

As a result we undertook an unannounced focused inspection on 22 December 2014 to follow up on whether action had been taken to deal with the breach.

You can read a summary of our findings from both inspections below.