We inspected this service on 21 March 2018. The inspection was unannounced.

Harper Fields is a purpose built home which provides accommodation with personal and nursing care for up to 80 people. There are four separate units within the home. Two are ‘memory lane’ units for people living with dementia. Another unit is for people with nursing care needs and the fourth is a residential unit. There were 75 people living in the home at the time of our visit.

At our last inspection in May 2017 we rated the service as good overall. However, we found a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 because risks around skin care and wound management had been not been addressed in line with people’s care plans. The key question of ‘Is the service safe?’ was therefore rated as requires improvement. The provider sent us an action plan, setting out the actions they planned to take to improve the quality of the service. At this inspection, we checked whether the actions they had taken were effective.

Since our previous inspection in May 2017 we have reviewed and refined our assessment framework, which was published in October 2017. Under the new framework certain key areas have moved, such as support for people when behaviour challenges, which has moved from effective to safe. Therefore, for this inspection, we have inspected all key questions under the new framework, and also reviewed the previous key questions to make sure all areas were inspected to validate the ratings.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At this inspection staff told us learning had been taken and shared following the issues previously identified around wound management. The registered manager had implemented procedures and processes to ensure people’s skin was regularly assessed and wounds were monitored regularly. Some improvements were still required to documentation, but the registered manager took immediate action to ensure staff had all the information required to check wound treatment plans were effective.

Staff were responsive to changes in people’s health needs and sought professional advice and support so people’s health was maintained. Overall, people received their medicines safely and as prescribed. However, the provider needed to ensure safe medicines management was consistently followed throughout the home.

People were safe from the risks of harm, because staff understood their responsibilities to protect people, and were encouraged and supported to raise concerns under the provider’s safeguarding policies. The registered manager checked staff’s suitability to deliver care and support during the recruitment process.

There were enough staff on duty to support people safely. Staff had the necessary skills and experience and received appropriate training and support from the registered manager to provide effective and responsive care.

People's needs were assessed before they moved to Harper Fields so the registered manager could be confident those needs could be met. Risks to people’s personal safety had been identified and plans were in place to minimise these risks. Accidents and incidents were investigated and actions taken to minimise the risks of a re-occurrence. The premises and equipment were regularly checked to ensure risks to people’s safety were minimised.

Staff had received training in the Mental Capacity Act 2005 and understood about working in accordance with people’s best interests and in the least restrictive way. Staff offered people choices and sought their consent before they supported them.

People were supported to eat and drink

The home provides accommodation with personal and nursing care for up to 80 people. At the time of our inspection 67 people were living at the home across five units although two of these operated alongside each other. At the last inspection in December 2014 the service was rated Good. Following this inspection the overall rating is Requires Improvement.

There was a registered manager in post at the time of our 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.

People and their relatives told us they were safe living at the home and were supported by sufficient staff. Staff were aware of how to keep people safe and who to report any concerns to if they suspected abuse. We saw nursing staff administer people’s medicines although the records were not always fully completed for some items.

Risks to people were assessed. We were not always able to fully assure ourselves people had their wounds dressed in accordance with their care plan and wound assessment. Information from handover sheets was not always transferred to the daily records and as a result nursing staff were not always able to tell us about people’s needs or events which had taken place.

Staff told us they were well supported by the management and liked their job. Management were available to offer guidance to staff and assisted in the provision of care as needed. Staff received training to assistant them provide the care and support people needed.

People were supported by staff to maintain their independence and choice about daily living. Staff had knowledge about providing care in the least restrictive way possible and had an awareness of how to maintain people’s privacy and dignity.

People enjoyed the food and had a choice available to them. Where people needed support from healthcare professionals for treatment this was arranged for them and advice and guidance given was followed by nursing and other staff members.

An extensive range of hobbies and interests were made available to many people who lived at the home and people enjoyed these opportunities. For people in one area of the home the amount of input was not so high and people were at times more withdrawn.

The registered manager was well respected. Relative’s spoke of the improvements made and had confident they were listened to. Systems were in place to seek the views of people and their relatives as well as to assess the quality of the service provided.

This inspection took place on 4 December 2014 and was unannounced.

Harper Fields opened in September 2012 and is registered to provide personal and nursing care for up to 80 people. The home is split into four units. Three of the units are “memory lane” units and provide care for people with a diagnosis of dementia. The fourth unit is for the “elderly frail”. At the time of our visit there were 70 people living in the home.

We last inspected the home in July 2014. After that inspection we asked the provider to take action to make improvements in how medicines were managed and records maintained. The provider sent us an action plan to tell us the improvements they were going to make. At this inspection we found improvements had been made in the management of medicines and record keeping within the home. This meant the provider met their legal requirements.

A registered manager was 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.

People told us they felt safe living at Harper Fields. The manager and staff understood their responsibilities for keeping people safe and reporting any observed or suspected abuse. There were plans in place to manage any potential risks to people’s health and wellbeing. Staff had received training to de-escalate any behaviour that could be challenging to others. Appropriate arrangements were being undertaken to manage the risks associated with the unsafe use and management of medicines.

There were processes in place to ensure staff received regular training and updates to make sure they had the skills to meet people’s needs. How staff were deployed through the home ensured the right skill mix to meet people’s needs safely and effectively.

The manager understood their responsibilities under the Mental Capacity Act and the Deprivation of Liberty Safeguards. These were put into practice effectively and people’s human and legal rights were respected. Staff understood issues around people’s capacity to make decisions.

People were provided with sufficient to eat and drink and people who had risks associated with eating and drinking had their food and drink monitored. Where changes in people’s health were identified, they were referred promptly to other healthcare professionals.

People and visitors to the home were positive about the caring and patient attitude of the staff at Harper Fields. During our visit we observed friendly and humorous interactions between people and the staff supporting them. Staff understood the importance of promoting people’s dignity and encouraging independence.

Care plans were detailed and reflected people’s needs, choices and preferences. They were regularly reviewed with the involvement of people and their relatives. Staff used their knowledge of people to deliver care that met their individual needs. People’s requests for assistance were responded to without delay.

People told us the service was well managed. Staff told us the management team was accessible and approachable. The manager was keen to encourage the personal development of staff in order to improve the quality of service provided.

During our last inspection on 20 May 2014 we had found non-compliance with medicine management and record keeping at the home.

At this inspection a pharmacist inspector from the Care Quality Commission visited the home in order to look at medicine management. We looked at medicine administration records and how the service administered, stored and managed medicines.

We looked at medicine care plans and medicine administration records on two units. We acknowledged that although there had been some improvements made following our previous inspection there were still continued areas of concern for safe medicine management. In particular we had received information that there had been some medicine errors on one unit. We looked at two recent medicine errors which involved pain relief medicines. These errors had only been identified by the service following discussion with the doctor. This meant that we could not be assured that people were safe from harm.

We found that appropriate arrangements were not always being undertaken in order to manage the risks associated with the unsafe use and management of medicines.

At this visit we found some improvements had been made in the maintenance of records within the home. However, we found that records around the management of wound and pressure sores were still not in good order. We could not be sure wounds and pressure sores were being managed in accordance with care plans. Daily records were still being completed inconsistently.

Two inspectors and a pharmacy inspector visited Harper Fields on 20 May 2014. Harper Fields opened in September 2012 and is registered to provide personal and nursing care for up to 80 people. At the time of our visit three of the four units were open and there were 60 people living in the home. Two of the units were “memory lane” units and provided care for people with a diagnosis of dementia. One of the units was on the ground floor and the other was on the first floor. The third unit was for the “elderly frail”. The fourth unit was also going to provide dementia care and it was anticipated it would be opened within the next month.

During our visit we spoke with the manager, the deputy manager, 10 care and nursing staff and the activities co-ordinator. The manager and deputy manager had been in post for approximately three months. We spoke with six people who lived at Harper Fields and two visiting relatives. We also had the opportunity to speak to a GP who attended the home on the afternoon of our visit.

We spent time in the communal areas of the home and observed the care and support provided to people. We looked at care records, staff records and quality assurance records. We used all the information we gathered during our visit to answer five key questions. Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

Below is a summary of what we found. If you would like to see the evidence supporting our summary please read the full report.

Is the service safe?

We looked at the care records for four people living at Harper Fields. Care plans were available for most of the identified needs of people and gave staff the information required to make sure the person's needs were met appropriately and safely. However, some records did not always provide staff with the information they needed to safely manage people with specific needs such as diabetes or catheter care.

We looked at medicine administration records on three units. On one unit we found that there were some errors in medicine records. This meant that it was not always possible to know if people had been given their prescribed medicines.

We found that appropriate arrangements were not always being undertaken in order to manage the risks associated with the unsafe use and management of medicines.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DOLS) which applies to care homes and hospitals. We saw that where any restrictions on a person’s liberty had been identified, the appropriate applications had been made to the local authority. The manager was aware of the latest guidance and information on DOLs and had arranged for an assessor from the local DOLS team to review people on one of the units to ensure their rights continued to be protected.

Is the service effective?

People we spoke with were happy with the level of care provided within the home. One relative told us, “The place is light and airy and immaculately clean. I come in at random times. I can't fault them - everyone from the cleaner, chef and care staff know people living here by their names."

The environment on the memory lane units provided people with a variety of visual and tactile stimulation.

Staff we spoke with knew and were able to tell us about people's health conditions and how they were managed. Staff ensured people had call bells to hand so they could call for assistance when necessary.

Is the service caring?

During our visit we saw some kindly and sensitive interactions between the staff and the people living in the home. One person became very anxious. We saw a member of staff reassuring the person and rubbing the person’s back as they talked to them. The person relaxed and said, “Oh you are so kind, so helpful.”

There were a range of activities available both inside and outside the home. People were encouraged to participate in trips to places of interest and various groups from the community were invited into the home. People were encouraged to move around the home and mingle with each other in order to facilitate friendships.

People and the relatives we spoke with were very complimentary about the staff working within the home. Comments included: “The staff are very good. They really are attentive.” "Excellent. I can't fault them." A member of staff told us they liked the person centred approach and added, "It's about what they want, not what we want, keeping independence .... respect for our elders - they have opinions."

Is the service responsive?

Records demonstrated the service was responsive in contacting other health care professionals to meet people’s changing health needs. The service had developed a good working relationship with the local GP practice to ensure people’s health needs were met and information was exchanged safely.

People told us they felt confident in raising any concerns with the manager and felt they would be addressed. One person told us about a concern they had raised with the manager which had been addressed to their satisfaction. A relative told us, “X has every confidence that if there is a problem it will be dealt with. They keep her informed.”

Is the service well-led?

We found the service had processes in place to ensure they took into consideration the views of people who used the service. A quality satisfaction survey carried out in autumn 2013 showed a high level of satisfaction with the service.

We saw the service maintained a system of audits and reports which identified areas where improvements were needed to ensure the service provided was safe and effective.

Three inspectors and a pharmacist inspector visited Harper Fields on 9 July 2013. The inspection was part of our annual inspection programme as well as a follow up to check on areas of concern identified at a previous inspection on 6 March 2013. Harper Fields opened in September 2012 and will provide nursing care for up to 80 people in six units. At the time of our visit two units were open providing care for 29 people. One unit provided dementia care and the other nursing care for the elderly frail.

Care plans were individualised and reflected the needs of people. We observed the support recorded in care plans being carried out in practice by the staff. The atmosphere in the home was calm and pleasant and all staff demonstrated a kind and caring approach to people. There were sufficient numbers of suitably qualified staff on duty to meet the needs of people.

We looked at medicine administration records and how the service managed medicines. We found that appropriate arrangements were not always being undertaken in order to manage the risks associated with the unsafe use and management of medicines. We observed medicines being given to people with patience, understanding and care. One person told us, "I wish I didn't take all these tablets but they know where to put my injection so it doesn't hurt me as much."

There were systems including internal audits in place to monitor the quality of the service provided.

Harper Fields opened in September 2012 and provides nursing care for up to 80 people. We visited Harper Fields on 6 March 2013 due to concerns about staffing levels, particularly at night. At the time of our visit the service was providing care to 37 people over three units. We focused our time within two of these units. One unit specifically provided dementia care and the other nursing care for the elderly frail.

People we spoke with during our visit were positive about the care and support provided. One person told us, “I am quite happy. I don’t think I could be in a better place.”

We looked at people's care records. We found they did not always contain sufficient information to support staff to deliver care that met people's needs and manage risks identified.

We spoke with staff and looked at staffing rotas. Staffing levels were determined by an assessment of people's dependency levels on admission to the service. We saw no evidence that people's dependency levels had been reassessed. We could not be sure staffing levels were based on people's current needs. Staff did not consistently have the skills to deliver the nursing care needs the service told people they could meet.