Heathcote is a converted residential care home without nursing for 29 people, some of whom are living with dementia. At our last inspection we rated the service Good overall and Outstanding in the Caring key question. At this comprehensive inspection, which we carried out on 18 and 24 September 2018 we found the evidence continued to support that rating of and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. Because the rating remains Good, this inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

Since our last inspection in 3 September 2015, there has been a change of registered manager, however, the people who lived in the service told us that they continued to feel safe and very well cared for. There were systems in place which provided guidance for care staff on how to safeguard the people who used the service from the potential risk of abuse. Staff understood their roles and responsibilities in keeping people safe. Risk assessments were still in place to identify how the risks to people were minimised. There continued to be sufficient numbers of trained and well supported staff to keep people safe and to meet their needs. Where people required assistance to take their medicines there were arrangements in place to provide this support.

Both the registered manager and the staff understood their obligations under the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). People living in the home were still being supported to have maximum choice and control of their lives and staff support them in the least restrictive way possible; the policies and systems in the service support this practice.

People’s needs were assessed and the service continued to support people to eat and drink enough to maintain a balanced diet. They were also supported to maintain good health and to have access to healthcare services.

We saw many examples of outstanding and positive caring interactions between the staff and people living in the service. People were able to express their views and staff listened to what they said and took action to ensure their decisions were acted on. Staff continued to strongly protect people’s privacy and dignity.

People received care that was personalised and responsive to their needs. The service still listened to people’s experiences, concerns and complaints. Staff took steps to investigate complaints and to make any changes needed. People were supported at the end of their lives to have a comfortable, dignified and pain free death.

The registered manager told us that they were well supported by the organisation. The people using the service and the staff they managed told us that the registered manager was open, supportive and had good management skills. There were still good systems in place to monitor the quality of service the organisation offered people to ensure it continued to meet their needs.

Further information is in the detailed findings below

Heathcote is registered to provide accommodation for up to 29 people who require personal care. At the time of our inspection there were 22 people living at the service. The service is located in the city of Norwich close to local amenities and facilities. Off road parking is provided as well as accessible premises for people, staff and visitors. Access to the accommodation is provided by stairs or a passenger lift to all floors of the three storey building. There are 25 single and four double occupancy rooms with en suite facilities.

At our previous inspection on 7 May 2014 the provider was meeting the regulations that we assessed. This unannounced inspection took place on 3 September 2015.

The manager had been managing the service since 2 February 2015. The manager had taken all appropriate steps to complete the application process to become the registered manager. 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.

The provider had a robust recruitment process in place. This helped ensure that staff were only recruited into their role where they had been deemed suitable to work with people living in the service. There was a sufficient number of suitably experienced staff working at the service. New staff were supported with their development with an effective induction process.

People were safely supported with medicines administration by staff who had been trained to do so. Staff’s competency to administer medication was regularly assessed to ensure they adhered to safe practice. Staff had a good understanding of what protecting people from harm was. Staff were trained and were confident in reporting poor standards of care should this occur.

The CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. The manager and staff were knowledgeable about assessing people’s ability to make specific decisions about their care. Applications to lawfully deprive four people of their liberty had been submitted. People’s care was provided where it was in their best interests.

People’s care needs were supported by staff who were attentive and showed compassion. Staff knew and understood people’s needs well. People’s privacy and dignity was respected by staff using the most appropriate means.

People planned their care with relatives, representatives and staff’s assistance. Regular reviews of people’s care were completed. People’s care and support was based upon the person’s latest and most up-to-date care information. The manager was aware of how people could be offered independent advocacy and also that provided by people’s relatives or friends.

People were supported to access a range of health care professionals including a dietician, GP or speech and language therapist. Health care professional advice was recorded, updated and adhered to by staff. Prompt action was taken in response to the people’s changing health care needs. Risk assessments to help safely support people with their health risks were regularly assessed and managed according to each person’s needs.

People were supported with their nutritional and hydration needs. This was so that people had the support they needed to maintain a healthy weight. Pureed and soft food diets and choices were available. Sufficient quantities of food and drinks were available for people to access when they wanted.

People were able to suggest changes or raise concerns before they became a complaint. Staff recognised and knew how to respond to people’s concerns. Information and guidance about how to raise compliments or concerns was clearly displayed.

A range of effective audit and quality assurance procedures were in place. These were used as a means of identifying areas for improvement and also where good practice had been established. Information was shared through a range of forums including residents’, managers’ and staff meetings.

Staff were supported with their personal development by managers who kept themselves aware of the day to culture in the service.

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 safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well led?

This is a summary of what we found.

Is the service safe?

We found that people were treated with dignity and respect. They told us they felt safe and would not wish to live anywhere else.

We found that the service had procedures in place to monitor the safety and quality of the service provided. Each person had received an assessment on their mental capacity and each person had been judged to have capacity. Records in care plans showed individual care and support needs were assessed so that they could be met safely. Risks had also been assessed and acted upon to minimise these are far as possible.

People were supported safely and correctly with their dietary needs. Meals and drinks were monitored and special diets listed for staff to follow.

All staff had received training in safeguarding and were aware of how to ensure people were safe and protected from possible abuse.

The monitoring and audit systems in place ensured that the service provided was offered safely and correctly.

One area of the home was a concern due to wheelchairs obstructing a fire exit. However, this was dealt with immediately and the obstruction removed to ensure people’s safety was not compromised in the event of a fire.

Is the service effective?

Relatives told us that this was the right home for their family member. They told us their views were listened to about all aspects of the care and support provided.

People living in the home were spoken with in meetings or on a one to one basis to gain their views. They told us they voiced their opinions and action was taken when requests or concerns were raised.

We found a supportive line management structure in this home that monitored the quality of the service to measure the effectiveness of the quality of the service provided.

People who did not have close family support were assisted with an advocacy service provided by ‘Age Concern’.

Is this service caring?

Throughout the day we overheard or observed interactions between staff and people living in the home. We heard choices offered, respect given, time given for people to do the task themselves, assistance when needed and encouragement to promote independence.

People we spoke with praised the staff team saying they were all good. Relatives and the GP praised the manager and the staff team for their caring approach to all aspects of the care and support provided.

Is the service responsive?

Where people were assessed as requiring more support than could be offered by the home further professional support was sought. Professionals were involved quickly to support people with their health needs. The GP told us that the home was effective. They said, “The staff know the people well and act and communicate with the surgery quickly.”

Meetings had been held and areas for improvement that were highlighted were acted upon. Improvements had also been introduced since the last inspection where ideas had been discussed and acted upon. Staff told us the manager had an open door policy and that they could and would voice any issues and that they would be acted on.

Although no-one had made a complaint the people we spoke with told us they knew how to complain and that the complaint would be acted on. We were told by the people living in the home and relatives how responsive the manager was and how any issues they may have were addressed quickly.

Is the service well led?

Heathcote had a registered manager in post who knew all the people in the home. They told us how they varied their time of arrival to ensure they would meet all staff to gain their views and monitor the service at different times of the day.

A quality monitoring system was in place comprising of audits, meetings, questionnaires and spot checks.

The home manager had registered with the care Quality Commission in March 2014. People using the service and the staff spoken with told us the management was good. They told us they were listened to and action was taken when appropriate.

We found during this inspection that people were offered care that was relevant to meet their needs. They told us they were happy. We received comments such as. “I know all the staff, they ask my opinion.” “I get involved and get told what is going on.” “I know I have a care plan and that information about me and my needs are documented.” “I choose what I want to do like going out regularly.” “I get taken to church if I want and the home has a service here as well.”

Care plans were completed and reflected the needs of people living in the home. They included any risks identified and action taken to reduce or remove the risks. Specialist advice was sought when required and staff had the skills required to offer appropriate care. This told us people's care and welfare was protected.

Meals were offered with choice and various nutritional needs were catered for. Drinks were encouraged and staff were aware of those not drinking enough. People who were at risk of a poor diet would be referred to a specialist. This would ensure people were supported with suitable and nourishing meals.

Medication procedures were followed and administration, storage and audit processes for medication were carried out safely.

Previously some concerns had been raised about the staff support, training and supervision arrangements. The home had now improved upon these concerns. Staff told us about the changes and record evidence showed that improvements had been made and that staff were now supported, skilled and better able to do their job.

The home had a number of systems in place that enabled them to measure and improve on the quality of the care that was provided.

People told us that they were happy with the way they were supported. They expressed their satisfaction with the staff. One person told us the staff were "...lovely...". "I can't say anything bad about them." Another said, "They're all alright." They said that, if they used their call bell, the staff "...come quickly." They told us that they had choices about food and that it was very good and hot when they were served their meals.

We found that there was inconsistent support for staff to carry out their roles effectively. Some training was slightly overdue, some staff received regular supervision but others did not. Appraisal did not always take place regularly but staff did have opportunities to gain qualifications to support them in their work.

People told us they felt that they were kept informed about what was going on in the home. People were aware of the problems with the home's lift and although one person was not happy that they were unable to go downstairs when they wished, they understood why this had happened and that the lift was going to be repaired soon after our visit. They told us that they knew how to complain if they needed to and they or their relatives would complain if it was needed.

People who live in the home confirmed that they are able to attend meetings where they can raise any concerns or issues that they have.

People told us that they felt safe and comfortable to talk to staff about any issues they may have. One person with whom we spoke said, "People here care about us and what I think." they are kind to me and listen".

We were told that staff in the home were very kind and respectful. One person with whom we spoke stated that, "they always employ kind people who know what they are doing". Another person stated tha, "staff respect my privacy and are really good". Another person we spoke with said that they had been at the home for eight years and liked the fact that staff were familiar to them and that they felt safe in knowing that the same staff would be working with them.

People said that they always found the home to be clean and tidy and the general consensus from people with whom we spoke stated that the staff were, "vigilant in making sure it always smelt nice and was always clean."

A person using the service told us that they felt safe at Heathcote. They said if something happened that they didn't like they would feel able to tell staff. Several people told us that they were happy living at the home. One said, "It's a happy place and people get looked after."