This inspection took place on 15 August 2018 and was unannounced. This meant the provider and staff did not know we would be attending.

The service was last inspected in December 2015 and was rated good. At this inspection we found the service remained good. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

Harmony House Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Harmony House Nursing Home accommodates up to 33 people with a range of mental health and physical conditions, and provides nursing and personal care. At the time of our inspection 28 people were using the service.

There were two registered managers in place. 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. One of the registered managers was also the provider of the service, and in this report we will refer to them as the provider.

People and their relatives said staff kept people safe. People’s medicines were managed safely. Risks to people were assessed and monitored. Plans were in place to support people in emergency situations. The premises were clean and tidy, and the provider had effective infection control processes. People were safeguarded from abuse. Staffing levels were sufficient to support people safely. The provider’s recruitment procedures minimised the risk of unsuitable staff being employed.

Staff received regular training in a range of areas relevant to people’s support needs and were supported with regular supervisions and appraisals. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice. People were supported to maintain a healthy diet. Staff worked with a wide range of external professionals to monitor and improve people’s health and wellbeing. The building had been adapted and customised for the benefit and comfort of people.

People said they were happy living at the service and that staff were kind and caring. People were treated with dignity and respect. Staff supported people to maintain their independence and live as full and free a life as possible. People were supported to access advocacy services.

People received personalised support based on their assessed needs and preferences. Support plans contained information on how people could be supported to communicate and engage effectively with the service. People were supported to access activities they enjoyed. Policies and procedures were in place to investigate and respond to complaints. Policies and procedures were in place to provide end of life care where this was needed.

The registered managers had informed CQC of significant events in a timely way by submitting the required notifications. This meant we could check that appropriate action had been taken. Staff spoke positively about the culture and values of the service. The registered manager and provider carried out a range of quality assurance audits to monitor and improve standards at the service. Feedback was sought from people, relatives, external professionals. The provider and registered manager had developed links with a number of community groups and bodies to help enhance the health and wellbeing of people using the service.

We inspected Harmony House on 11, 24 December 2015 and 15 January 2016. This was an unannounced inspection which meant that the staff and provider did not know that we would be visiting the first day or exactly when in the following weeks.

Harmony House is a nursing service that until recently provided care for up to 33 people with mental health needs. The service operates over three floors. The number of places increased on 30 December 2015 as the provider had identified that the service could be developed and enhanced so purchased the adjacent building. They have totally and carefully renovated the building to provide an additional 12 bedrooms, another two bathrooms, an additional office and more communal space.

The provider is the registered manager and has been in this role since they commenced operating the service in 2011. A provider 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 time of the inspection 21 people lived at the service and we met nine of the people who used the service. They told us that they were very happy with the service and found it met their needs.

We found that the provider and staff consistently ensured people were supported to lead an independent lifestyle. The registered provider had purchased a mini-bus and designed a programme of activity that enabled people with different skill sets to fully engage in a range of activities within the community. We heard from the people that they thoroughly enjoyed these activities.

Staff readily identified triggers that would lead people to become distressed or that their mental health was deteriorating. We found this had a very positive impact on people and led to a marked reduction the number of occasions people were admitted to hospital. Also we found that the staff’s extensive knowledge of people had enabled them to readily spot changes in people’s presentation and this had led to the staff taking prompt action to prevent people causing significant harm to themselves .

We saw that detailed assessments were completed, which identified people’s health and support needs as well as any risks to people who used the service and others. These assessments were used to create plans to reduce the risks identified as well as support plans. We found that the registered provider had fully embedded a computerised system for recording care delivered at the service and this was very effective.

We saw that people were offered plenty to eat and assisted to select healthy food and drinks which helped to ensure that their nutritional needs were met. We saw that each individual’s preference was catered for and people were supported to manage their weight.

We saw there were systems and processes in place to protect people from the risk of harm. We found that staff understood and appropriately used safeguarding procedures.

People were supported to maintain good health and had access to healthcare professionals and services. People were supported and encouraged to have regular health checks and were accompanied by staff to hospital appointments.

Staff were aware of how to respect people’s privacy and dignity. We saw that staff supported people to make choices and decisions.

Staff had received a range of training, which covered mandatory courses such as fire safety, infection control and first aid as well as condition specific training such as working with people who have learning disabilities. Staff had also received training around the application of the Mental Capacity Act 2005 and the Mental Health Act 1983 (amended in 2007). The staff we spoke with understood the requirements of this this legislation.

Staff shared with us a range of information about how they as a team worked very close

We completed this inspection to look at the measures the provider had taken to ensure staff understood the requirements of the Mental Capacity Act 2005 and Mental Health Act 1983 (amended 2007) when working with people at the home.

The people we spoke with during the visit told us that they liked living at the home and that the staff were good at their jobs. One person said, “This is a good place. The staff are fine.”

We found that since the last inspection in October 2013 the owner/manager had provided additional training for staff around the application of the Mental Capacity Act 2005 and reviewed the nursing staff’s understanding of the Mental Health Act 1983 (amended 2007) code of practice. He had introduced the range of documents required when a person appears to lack the capacity to make decisions. We found that the work completed at the home ensured people could lead the least restrictive lifestyle and the people we spoke with confirmed that this was the case.

Following our last visit the owner/manager had worked with the consultants and approved social workers to ensure they had a full list of conditions people were subject to and that these could be applied in this setting.

We found that the owner/manager had introduced a computerised record system and this readily supported staff to detail clearly all the actions that they took and how they worked with the people who used the service.

We spoke with seven people who used the service. All of the people we spoke with told us that they found the staff were good at their jobs, the home was well-run and they liked living at Harmony House. One person said, “This is a very good home, the staff are smashing and the manager is good.” Another person said, “The staff always help me and are kind”. People told us that they got plenty to eat and always were offered choices at meal times.

Some people had limitations placed upon them around going on leave the building independently and how much they smoked. Some of the people we spoke with told us that they had agreed to these limitations, as they were in their best interest. They found that without help people had run out of cigarettes before they received their following week’s money. People also said that because of their physical health they needed someone to go with them when they went out. However, these agreements had not been recorded in their care plans.

We found that although the provider had ensured all the staff completed training around determining if people had capacity to make decisions and when they could restrict people’s lifestyles, they had not applied this to their practice. We also found that staff needed to gain more awareness around the use of Community Treatment Order conditions.

We found that staff received a wide range of training and were very knowledgeable about people’s care needs and mental health conditions.

The visit took place because we were following up compliance actions made at the previous inspections in May and July 2012 around staff training, management of monies, record keeping and quality assurance. Therefore when talking with people we concentrated on these specific areas. We spoke with six people who used the service. They told us that they were happy with the service and found the staff approachable but their information did not relate directly to the areas we were reviewing at this inspection.

People said “They are a good bunch and I like it here”, “The staff are good” and “I have no complaints at all it is a good service”.

We did not speak with people who used the service during this inspection.

We spoke with five people who used the service during the inspection. They told us that

the home had improved and they were involved in making decisions about the care and support received and that they felt well supported.

One person told us about the voluntary work he does, which kept him busy and also about how much calmer he had been feeling over the past six months. He said "The staff are very good and I can always talk to the manager if I'm beginning to get anxious." Another person showed us how he uses the home's computer to contact and chat to his daughter. He said "The manager showed me how to use the computer and it's fantastic."

One person talked about the football game he had been to with the activities person and how much he had enjoyed it.

One person commented "I'm pleased with my room, it's just been decorated and I chose the colours." Another person said "The home is much better, homely."

A person spoken to said "I feel safe here, staff look after me."

One person said that all the staff were good. Another person said they thought everything fine.

People spoken to said they had choices in their daily routine. One person said "I might go out for a walk or go to the local shops." Another person said "I like a lie in and watch television in bed."

People said " The food is good, I have a choice." One person thought their health needs were being met and had been seen by their consultant.

A person said "There are some incidents between people in the home" but they felt safe and if they had any concerns would speak to a member of staff.

People said "The staff are brilliant, they will help you in any way they can." "I have a key to my room, I can come and go as I please."

We were told that "Everything is as it should be."