Horton House 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. Horton House can accommodate up to 24 people. At the time of our inspection there were 22 older people living there of whom 17 were diagnosed as having dementia. Horton House provides family style accommodation in the middle of Gloucester. People each have their own bedroom which they have personalised and share bathrooms, a lounge, dining room and conservatory. The garden to the rear is accessible.

This inspection took place on 7 and 8 August 2018. At the last comprehensive inspection in February 2016 the service was rated as Good overall.

At this inspection we found the service remained Good.

People’s care was individualised and person centred, reflecting their backgrounds, likes and dislikes and needs. Staff understood them really well. People’s needs had been assessed and were monitored and reviewed each month or sooner if their needs had changed. Their relatives were involved in this process and kept informed about any changes. 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 encouraged to be as independent as possible. Staff encouraged them to do as much as they could for themselves. Risks were assessed and strategies were in place to minimise any hazards. People felt safe living in the home. They had been asked about which activities they would like to take part in. These included music for health, drama and arts and crafts. People were supported individually to go out for walks, for lunch or on day trips. They were supported to attend a place of worship. Friends and family were able to visit whenever they wished. People used video links and the telephone to keep in touch with them.

People were supported to stay healthy and well. Their nutritional needs were closely monitored. Special diets were provided if needed. People were encouraged to drink hot and cold drinks. If they needed help to eat this was provided by staff. People had access to their GP, optician, dentist and chiropodist. Staff liaised closely with health care professionals. People’s medicines were managed safely.

People were supported by enough staff to meet their needs who had been through a satisfactory recruitment process. Staff felt supported in their roles and had access to refresher training to keep their knowledge and skills up to date. Staff were knowledgeable about people, their backgrounds and individual needs. People were treated with respect and sensitivity. They had positive relationships with staff and enjoyed spending time in their company. Staff understood how to keep people safe and were confident any concerns they raised would be listened to and the appropriate action taken in response.

People’s views and the opinions of their relatives and staff were sought to make improvements to the service provided. Annual surveys had been completed and improvements had been made to the service as a result. The provider and registered manager worked as part of the team enabling them to lead by example and to also ensure their values were embedded in people’s experience of their care. People told us, “Staff are so helpful and friendly, nothing is too much trouble” and “It’s beautiful here.”

Quality assurance processes were carried out by the registered manager and provider to make sure the standard of care they wished to provide were maintained. The registered manager said, “We are always aiming for the best, for excellence. The delivery of high standards of care is embedded in the way we work.”

Further information is in the detailed findings below.

This was an unannounced inspection which took place on the 11 January 2017. Horton House Residential Care Home provides accommodation for up to 23 older people. At the time of our inspection there were 23 people living there. Of these people 20 had been assessed as unable to make decisions about their care and support.

Horton House is a family run home. People in 12 bedrooms had en-suite facilities. They also had access to a shared bathroom and shower room as well as living and dining areas. A conservatory at the rear of the home provided additional space for activities and to meet with visitors. The grounds around the home were accessible to everyone.

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.

We carried out an unannounced comprehensive inspection of this service on 5 January 2016. A breach of legal requirements was found. After the comprehensive inspection the provider wrote to us to say what they would do to meet legal requirements in relation to the breach.

We undertook this focused inspection to check that they had followed their plan and to confirm they now met legal requirements in relation to a breach of regulation 13. This report only covers our findings in relation to this requirement. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Horton House on our website at www.cqc.org.uk”

At the comprehensive inspection of this service on 5 January 2016 a breach of legal requirements was found. After this comprehensive inspection, we asked the provider to take action to:

• ensure that people who had been deprived of their liberty had the appropriate authorisations in place.

At this inspection we found action had been taken to submit authorisations to the supervisory body for people who were unable to make decisions about their care and support and whose liberty had been restricted. There was evidence that wherever possible the least restrictive solution was found. Bed rails were not used instead people were provided with beds which could be lowered and crash mats were placed on the floor. People who liked to go out for walks could walk freely in the secure rear garden or go out with staff. The registered manager had developed a monitoring tool so that she could monitor when each person’s Deprivation of Liberty Safeguard needed reviewing.

The provider had displayed the rating for this service on their website and in the home.

This inspection took place on 5 and 6 January 2016 and was unannounced. Horton House Residential Care Home provides accommodation for up to 23 older people. At the time of our inspection there were 20 people living there.

There were 15 people living with dementia in the home. People in 12 bedrooms had en-suite facilities. They also had access to a shared bathroom and shower room as well as living and dining areas. A conservatory at the rear of the home additional space for activities and to meet with visitors. The grounds around the home were accessible to everyone.

Horton House Residential Care Home had a registered 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.

People were being deprived of their liberty to keep them safe from harm. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005.

People received personalised care which reflected their individual wishes, likes and dislikes and routines important to them. Their capacity to consent to aspects of their care had been assessed and decisions taken in their best interests when needed. People were offered choices about their day to day lives and staff respected their decisions. People had positive relationships with staff who treated them respectfully and kindly. Staff offered reassurance when people were upset or anxious and helped them to become calmer. Staff had a good understanding of people’s needs which were clearly detailed in their care plans. Changes to people’s needs were responded to in a timely fashion to help them stay well and to ensure they had access to the appropriate health care professionals. People’s medicines were managed safely.

People were kept safe from harm. The recruitment and selection of staff was satisfactory ensuring they had the right skills and knowledge to meet people’s needs. There were sufficient staff to support people and staffing levels were adjusted when people were unwell or needed additional support. Staff were supported to keep their knowledge up to date, completing a range of training including courses specific to people’s needs such as dementia. Staff felt supported in their roles and were proud of their professional development.

The home was managed well and the registered manager had high expectations of the staff team and the standards of care delivered. A relative told us, “The registered manager is proud and particular, staff do their utmost to keep up her standards.” Robust quality assurance processes monitored the quality of the service provided. People, their relatives and staff were encouraged to voice their opinions about the service and action was taken in response. The registered manager worked effectively with health care professionals and external local and national organisations to promote people’s health and well-being and best practice. A relative commented, “The care you show, not just to my mother but to other residents, is second to none.”

We found a breach 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 this report.

Our inspector set out to answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, and the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People were treated with respect and dignity by the staff. People told us they felt safe.

Staff supported people to take informed risks with minimal necessary restrictions.

Systems were in place to make sure that managers and staff learnt from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve.

The home had proper policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards although no applications had needed to be submitted. Relevant staff had been trained to understand when an application should be made, and in how to submit one. This meant that people will be safeguarded as required.

There were clear procedures for giving medicines in accordance with the Mental Capacity Act 2005.

Prescribed medicines (including Controlled Drugs) were stored and administered safely in line with current and relevant regulations and guidance.

People were safe because staffing levels were sufficient to meet their identified needs. The registered manager set the staff rotas, they took people’s care needs into account when making decisions about the numbers, qualifications, skills and experience required. This helped to ensure that people’s needs were always met.

Is the service effective?

There was an advocacy service available if people needed it, this meant that when required people could access additional support.

People’s health and care needs were assessed with them. Specialist dietary, mobility and equipment needs had been identified in care plans where required.

Support plans reflected people’s current individual needs, choices and preferences.

People’s health was regularly monitored to identify any changes that required additional support or intervention.

Referrals were quickly made to health services when people’s needs changed.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. People commented, “They’ve been very good to me here, excellent”, “They look after me." People said that staff knew their needs “very well” and “they’re very good”.

People using the service, their relatives, friends and other professionals involved with the service completed an annual satisfaction survey. Where shortfalls or concerns were raised these were addressed.

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

Is the service responsive?

People, and those that matter to them, were encouraged to make their views known about their care, treatment and support.

Staff made sure that people had the time they needed to make decisions, taking account of the urgency of the situation.

People completed a range of activities in and outside the service regularly.

People were enabled to maintain relationships with their friends and relatives.

People knew how to make a complaint if they were unhappy. One person told us “I wouldn’t fault them for anything” and another said “I don’t think I could make a complaint, everything’s ok”. The manager informed us that there had been one complaint in the past year, when this was investigated it was found to be unfounded. People can therefore be assured that complaints were investigated and action was taken as necessary.

Is the service well-led?

The service worked well with other agencies and services to make sure people received their care in a joined up way.

Senior management were aware of the culture of the service and they kept this under review. This was to ensure that care was centred on people's needs and their rights were protected. Staff knew and understood what was expected of them.

CQC requirements for the submission of notifications and other legal obligations, were not met. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to notifications.

Resources and support were available to the manager and the team to develop and drive improvement.

The service had a quality assurance system, records seen by us showed that identified shortfalls were addressed promptly. As a result the quality of the service was continuingly improving.

We spoke with four people living in the home, a visitor and six members of staff. People told us they were happy with the care they received and that staff were very good. One person said, "staff treat me respectfully". A visitor told us "its a perfect home" and "excellent care, I am very pleased he is here. We couldn't have found better".

People talked to us about the range of activities they had access to. They enjoyed going out to garden centres and had a boat trip planned. A visitor told us, "there is lots to do, games, bingo, quizzes and art". One person said they enjoyed taking communion and used a local church.

People's needs were assessed and their care records reflected their likes, dislikes and routines. Key workers met with people to discuss their care needs. People had access to a range of health care professionals.

The home was clean, tidy and well maintained. Day to day maintenance was dealt with in a timely fashion. There were plans to extend communal accommodation by adding a conservatory to the rear of the home. People told us the home was kept clean and tidy.

Equipment was provided for those people who needed it. This was clean and well maintained. Where people's needs changed they were referred promptly for an assessment for equipment.

Staff had access to a range of training providing them with the knowledge and skills to meet people's needs.

People knew how to make a complaint and they said they had no concerns or issues.

We spoke with six people, four visitors and had feedback from social and health care professionals. We talked with people about the care and support they received. They told us, "I am very well looked after"," they will accommodate anything I want".

Visiting relatives said there had been lots of improvements including more activities and trips out. One relative commented, "I couldn't ask for anything better, its home from home". Another said, "its small and friendly, they are looked after well".

We talked to people about their home. They told us, the home was kept clean and tidy. They said they had no complaints about the cleanliness of their rooms. Visitors told us "it is home from home".

People told us there were enough staff to meet their needs. One person said "there are always staff around". People said they had no complaints or concerns about the care they received.

A person told us "can't fault the staff. It's lovely here." They said, "the meals are good and during the hot weather they have made sure that we have lots of drinks to keep us cool." Another person said they liked the activities including an art class and singing session. People told us they were enjoying their lunch of roast chicken and vegetables. People said they would talk to staff or the manager if they had any concerns.

Visitors stated, "its fantastic here. There has been a vast improvement in the physical health of .... due to the care here." Other visitors said their relatives were well looked after.

People said the home had a lovely relaxed atmosphere and that staff were very friendly. They told us staff were "great", "very helpful" and "immensely patient." They said they enjoyed the meals which were plentiful. They always had a choice and were offered snacks and drinks in between meals. They told us about the activities which were provided including games, arts and crafts, music and a quiz. They said they liked to go out to garden centres in the warmer weather. People said their rooms were kept clean and warm. They stated that they did not have to wait for staff to answer call bells. One person said "nothing is too much trouble for staff."