What life is like for people using this service:

The provider needed to ensure that any issues with people’s care were identified and that action was promptly taken to make improvements.

There were positive examples of how people’s risks were managed to help keep them safe. However, the lack of effective monitoring systems impacted on the quality and safety of people’s care.

Some people had to wait for the support they needed and there was no effective approach to identifying the staffing levels required.

Staff and the registered manager knew people well however, documentation did not always reflect what they told us.

People mostly felt happy with the care they received. Staff were kind and considerate towards people and knew their preferences, likes and dislikes.

We have made a recommendation that the provider reviews the way they gather people's feedback, to ensure people's voice is heard.

People were involved in planning and reviewing their care. However, reviews and checks were not always effective in identifying issues and ensuring action was taken.

The service met the characteristics of Requires Improvement in most areas;

More information is in the full report.

Rating at last inspection: Requires Improvement (published 10 October 2017)

About the service: Highbarrow Residential home is a residential care home. It accommodates up to 22 people in one adapted building. At the time of the inspection 22 people were living at the home.

Why we inspected: This was a planned inspection based on the rating at the last inspection. At the last inspection in 2017, we asked the provider to take action to make improvements. Some action has been completed however further improvements are required. This is the second consecutive time the service has been rated Requires Improvement.

Enforcement: Two breaches of regulations were identified during this inspection. You can see what action we told the provider to take at the back of the full version of the report.

Follow up: We will request an action plan from the provider to understand what immediate action they will take to improve the quality and safety of care provided to people.

This inspection took place on 15 August 2017 and was unannounced. At the last inspection on 8 December 2015, the service was rated as Good overall, however we had asked the provider to ensure medicine stocks were accurately recorded. At this inspection we found the required improvements had been made, but we found other concerns with the management of medicines. We also found risks associated with people’s safety and wellbeing were not always managed safely.

Highbarrow Residential Home provides accommodation for up to 22 people who require accommodation and or personal care. At the time of our inspection, the home was fully occupied. Some people at the home were living with dementia. There was a registered manager at the service. 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.

Improvements were needed to the management of medicines to ensure staff took a consistent approach when administering medicines prescribed on a when required basis and that people’s records were accurately maintained. The provider did not have effective systems to ensure risks to people were effectively assessed, monitored and reviewed. Improvements were needed to ensure the registered manager and provider’s checks were consistently effective in identifying shortfalls and were driving improvements. The registered manager did not always act in accordance with their registration and notify us of important events that occurred in the service.

Staff sought people’s consent before supporting them. However, improvements were needed where people lacked the capacity to make certain decisions for themselves to demonstrate that their rights were being upheld.

The daily routine at the home did not always promote personalised care that was responsive to people’s needs. Improvements were needed to ensure people were always able to take part in activities and social events that promoted their wellbeing and social inclusion.

There were sufficient, suitably recruited staff to meet people’s needs. Staff were trained and supported to provide people’s care effectively. People had sufficient amounts to eat and drink and accessed the support of other health professionals when needed.

Staff had caring relationships with people, promoted people’s privacy and dignity and encouraged them to maintain their independence. People were encouraged to keep in contact with family and friends and visitors were able to visit without restriction.

There was a positive, inclusive atmosphere at the home. People and their relatives felt able to raise concerns and complaints. People’s views were sought in the planning of the service, but changes made were not always monitored to ensure they were effective. Staff felt supported by the registered manager and provider.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

This inspection took place on 8 December 2015 and was unannounced. At the last inspection on 23 July 2014 the provider was not meeting the legal requirements. We asked them to make improvements to ensure there were enough suitably staff available to meet people’s needs. We received information from the provider which demonstrated how the legal requirements were being met. At this inspection, we found the required improvements had been made.

Highbarrow is registered to provide accommodation and personal care for up to 22 people who may have dementia. At the time of our inspection, there were 19 people living in the home.

There was no registered manager but the manager working at the home had begun the process of registering with us. 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.

There were systems in place to monitor the quality of the service which included checks on the accuracy of care plans and monitoring accidents and incidents to avoid reoccurrence. However, improvements were needed to ensure audits of medicines were effective in identifying shortfalls in the recording of stocks. Medicines were stored safely and people received their medicines as prescribed.

People and their relatives told us they felt safe. People told us the staff responded to their needs promptly but on some occasions staff asked them to wait a little longer during busy times. We saw there were enough staff on duty to meet people’s needs in a timely manner. The provider followed procedures to ensure they recruited staff who were suitable to work with people.

Staff knew people’s needs and followed plans to manage identified risks to people’s health and wellbeing. Staff understood what constituted abuse and knew how to raise their concerns to protect people from the risk of harm.

The manager and staff acted in accordance with the requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). The information in people’s assessments and care plans reflected people’s capacity when they needed support to make decisions. The manager had also made referrals for DoLS approvals where people needed to be deprived of their liberty in their best interest.

Staff received training and support to meet the needs of people living in the home. Staff had caring relationships with people and were attentive to their needs. People received food and drink that met their nutritional needs and were referred to other healthcare professionals to maintain their health and wellbeing. People were able to participate in leisure activities to promote their wellbeing.

People felt able to raise any concerns with the manager who took action when people brought things to their attention. There were processes in place for people to express their views and opinions about the home.

The concerns we received were that some staff working at the home had not had the proper recruitment checks or any training and that there were not enough staff on duty to meet people’s needs. At the time of our visit 13 people were using the service. We looked at staff recruitment and training records and the staff rotas. We spoke with staff, people using the service and one person’s visitor and a visiting professional. We also spent time in the communal areas of the home to observe the staffing levels in place and looked at the quality monitoring systems in place to check if the service was well led. We used the information we gathered to answer the following questions.

Is the service safe?

One staff member did not have a criminal record bureau (CRB) check on file at the time of the inspection. The provider sent evidence after the inspection that demonstrated that this check had been undertaken. This meant that the appropriate recruitment checks were in place to ensure people were cared for by staff that were safe to work with them.

None of the people who used the service raised any concerns regarding the numbers of staff on duty although they did confirm that there had been occasions when they had to wait for staff support.

We observed three occasions when there was no staff member in the communal lounge and one occasion when a person had to wait fifteen minutes to be supported to use the toilet. No assessment tool was in place to determine the staffing levels based on people's needs. Following the inspection the provider produced a tool to determine staffing levels based on people's needs. However this was ineffective as it underestimated the level of need of people in the home.

Is the service effective?

There were some gaps within the records seen regarding staff training and supervision, but we saw that this was being addressed by the new manager and provider to ensure staff were supported appropriately.

Is the service well led?

A new manager had been in post for one week at the time of our visit. We saw that actions had been taken by the new manager to monitor the standards in place at the home and identify where improvements were required.

All of the people using the service told us that the new manager was approachable and friendly. Some staff we spoke with felt it was too soon to make a judgement about the new manager. One person said; “She has only been here a week so it’s difficult to say what I think, she seems ok.” Other staff told us that they believed the home was more organised. One person said; “It seems more organised now, everyone knows what they’re doing, it wasn’t very organised before. I have been asking for certain training since I started and now it’s been booked.”

In this report, the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time.

This was an unannounced inspection. At this inspection we also followed up on issues we identified at the last two inspection visits in August and November 2013. We found concerns at the two previous inspections in relation to the care and welfare of people using the service and with the staffing levels in place to support people. At the time of this visit 14 people were using the service. We looked at two people’s care records and spoke with these people to get their views on the quality of support they received. We also spoke with the staff that supported them. This is known as pathway tracking and helps us to understand the outcomes and experiences of a selected sample of people. We also spoke with five other people that were using the service and one person’s visitor.

Is the service safe?

People told us they felt safe and had no concerns regarding the staff that supported them. One person told us; “I feel very safe with the staff, they are all lovely.” Another person said; “I feel much safer here than I did at home, this is a nice place and I have never felt unsafe here.”

Staff spoken with had a good understanding regarding the level of support each person required to maintain their safety and well-being.

Information within care plans and risk assessments demonstrated that people were supported to maintain their safety whilst keeping as much independence as possible.

Two care staff were on duty at night. Information within people’s records confirmed the level of support they required in the case of fire or other emergency situations. At our last visit we were advised that one member of staff lived within the grounds of the home and could be available to provide additional cover at night. However this person also covered night shifts, which meant that on these occasions this additional cover would not be available. Although the manager confirmed that they were on call and could be available at the home within 15 minutes, this time frame would not be effective in an emergency situation. The provider may wish to consider if the current night staffing arrangements would be sufficient to maintain people’s safety in emergency situations.

Is the service effective?

Discussions with people using the service and information in care records showed that people’s needs and preferences were being met.

People spoken with confirmed that staff respected their wishes and supported them as needed. People confirmed that they were consulted about their care plans and involved in decisions about the support they received. One person told us, “I manage most things myself but the staff are always checking with me that I’m ok and I am consulted about things.”

Since our last visit the staffing levels during the day had increased. Along with the manager of the home there was three care staff on duty. This enabled one member of staff to remain in the communal lounge when it was occupied, whilst the other two care staff supported people with their care needs as required.

The staffing levels at night had not been increased at the time of our visit and there was two staff on duty at night. Out of the 14 people using the service, three people required the support of two staff with hoisting for personal care needs. Although the majority of people told us that staff attended to them promptly, there was the potential that some people may have to wait at night for staff support.

Is the service caring?

We observed a positive working relationship between the staff and the people they supported. People using the service said that they like the staff and confirmed they did a good job. One person said; “Without exception all staff are very kind and helpful.” Another person told us; “The staff are all very good, they work hard and are always kind and friendly.”

People’s preferences and diverse needs had been recorded and care and support had been provided in accordance with people’s wishes.

Is the service responsive?

People we spoke with told us that if they had any concerns or worries they would tell a member of staff or a family member.

From our observations we saw that people using the service appeared relaxed and comfortable with the staff on duty and were able to openly express their opinions and preferences.

We saw that staff responded promptly to ensure people’s needs were met, for example when people requested support to use the toilet staff responded and we observed staff treating people respectfully, ensuring their dignity was maintained.

Is the service well-led?

Since our last visit a new manager had been appointed. People who used the service, visitors and staff spoken with were very complimentary regarding the new manager.

The visitor spoken to confirmed that meetings were held at the home on a regular basis to keep relatives up to date with any issues and how these were being addressed.

The visitor spoken with told us; “She [the new manager] has made such a difference because she’s so approachable and available.” This person also confirmed that the owner of the home was also available on a regular basis to discuss any concerns or issues.

Staff were clear about their roles and responsibilities and spoke positively about the management support they received. Staff told us that they were being provided with monthly supervision sessions and team meetings and confirmed that they found these beneficial in undertaking their job.

We completed this inspection to follow up on issues we identified when we last inspected this service on 19 August 2013. We found concerns during the previous inspection in relation to care and welfare of people using the service and with the staffing provided in the home.

We found that some improvements had been made. There were more opportunities for people to engage in activities appropriate to their abilities. However, we were concerned that some people may be at risk during the evening and night as there were not enough staff on duty to meet people’s identified needs and respond to emergencies.

We saw that staff engaged with people in a caring and friendly manner, but there were occasions when people did not receive prompt support from staff. Some people had been placed at risk as agreed care plans and assessments of risk had not been followed to prevent harm.

People’s care records contained up to date information although care had not been planned in a way which would guide staff to deliver care in accordance with people’s needs. This placed people at risk of harm.

There remains poor outcomes for some people and therefore the service will be subject to a management review by us. This is a key part of the enforcement process whereby we set out what we will do to get the care provider to improve their service. The action we will take will depend upon what effect this is having on the people using the service and how the care service provider responds.

This was a responsive follow up inspection to Highbarrow residential home. We wanted to see what the service had done to improve on areas we had identified in a previous inspection which had needed improvement. We also wanted to look at areas which had been highlighted to us as concerns by people who used the service or people acting on their behalf. The previous inspection took place on 22 April 2013.

In order to make our judgements we spoke with eight people who used the service, five members of staff, and we liaised with a fire safety officer at the regional fire and rescue service.

We found that some care records contained conflicting information, staff did not always know what people’s needs were, and people did not always receive care in a responsive and timely manner.

Medication was kept safely and given to people as prescribed.

The buildings had been improved to ensure they were compliant with current fire safety legislation.

Staffing levels meant that at some times of the day people did not always receive the care they needed when they needed it. One person said, “They do their best”.

We carried out this inspection to check on the care and welfare of people using this service. The inspection was unannounced which meant the provider and the staff did not know we were coming. We spoke with five people using the service, three staff and the registered manager.

Where people were not able to express their views we observed interaction between people and the staff. We saw staff provided sensitive support and people using the service were treated with respect. One person told us, “The girls know what they’re doing, and they ask us what we want.”

There were limited activities within the home and there were no specific services provided for people who had dementia related conditions. One person told us, “We like playing the word games, but some people aren’t able to join in.” This meant people could not be confident all their identified needs were being met.

Information about when people needed additional medication was not recorded to demonstrate why it was necessary. This meant people could not be confident they had all medication as prescribed and required.

The staff told us they enjoyed working at the home. We saw that all the checks were made to ensure staff were fit and suitable to do their job.

The staffing was not arranged to ensure people could have all their assessed needs met appropriately. Staffing arrangements did not allow for the safe evacuation of people in the case of an emergency.

We inspected this service on 25 October 2012 and found they were not compliant in relation to, respecting and involving people who use services, care and welfare of people who use services, management of medicines and requirements relating to workers. This meant the registered provider had to make improvements in these areas to deliver good outcomes for the people who used their service.

On this inspection we went to check that improvements had been made with regards to the management of medicines. We could not inspect the other areas of non compliance because the provider’s action plan said they would not be compliant in these areas until 31 December 2012. We will carry out a further inspection to ensure improvements in these areas have been made.

We needed to check medicine management had improved because this was a major concern to us. The inspection was unannounced, which meant the registered provider and the staff did not know we were coming. We looked at the evidence available following the action plan we had received from the registered provider, and we spoke with people using the service and some of the staff on duty.

Some people using the service told us they were happy with the care and support provided. They said the staff were patient and kind. One relative told us, “I think it is fantastic here.”

Other people using the service did not consider they were able to make choices. They told us the staff decided when they went to bed, had a bath or were woken. One person told us, “I have a bath once a week when they can do it, it depends who is waiting.”

We observed the staff and saw they provided sensitive support, and people were treated with respect. People using the service said the staff would always knock on their door.

We looked at care plans and talked to the staff about the care that was provided. We found information was conflicting and some staff had not read the care plans. This meant the provider could not ensure people had their needs met in a consistent and safe way.

We checked medication was stored, dispensed and administered in a safe way. We found people using the service were not suitably protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines.

We looked at the recruitment procedures for staff and found that overall suitable systems were in place but the provider had not ensured all records were completed to protect people using the service.

We found complaints were responded to and the provider acted upon concerns to improve the service.