What life is like for people using this service:

People were supported by safely recruited staff who had the skills and knowledge to provide safe and effective support. People were supported safely to manage their risks, whilst promoting their independence. Medicines were managed safely. Effective care planning was in place which guided staff to provide support that met people’s needs which were in line with their preferences.

People consented to their care and were supported in their best interests. People were supported to eat and drink sufficient amounts in line with their assessed needs. People’s diverse needs had been planned for which ensured they received individualised care in all aspects of their life. Professional advice had been sought and acted on to ensure people’s health and wellbeing was maintained. Systems were in place to ensure people received consistent care across the service and when accessing external services.

Staff were kind and caring towards people and promoted choices in line with individual communication needs. People were treated with dignity and their right to privacy was upheld.

People were supported to be involved in hobbies and interests that were important to them. People and their relatives were involved in the planning of their care, which meant people were supported in line with their preferences. Complaints systems were in place, which people and relatives knew how to use. People’s end of life wishes and needs were taken into account to ensure they received individualised care at this time of their lives.

Systems were in place to monitor the service, which ensured that people’s risks were mitigated and lessons were learnt when things went wrong. There was an open culture within the service, where people and staff could approach the registered manager who acted on concerns raised to make improvements to people’s care. The provider continually sought ways to improve the service people received.

The service met the characteristics of Good in all areas; more information is available in the full report below.

Rating at last inspection:

Requires Improvement (supplementary report published 15 December 2018)

About the service:

Scotia Heights is a care home that was providing personal and nursing care to 48 people at the time of the inspection.

Why we inspected:

This inspection was brought forward due to information of concern we had received and to check the provider had made improvements since the last inspection.

At the last comprehensive inspection in February 2018 the service was rated requires improvement overall (in the key questions of Safe, Responsive and Well Led). There was a breach in regulation because the governance systems in place were not effective in identifying and mitigating risks to people, which placed them at risk of poor care.

We carried out a responsive inspection in June 2018 and July 2018 due to information of concern and found improvements were still required in the key questions of Safe and Well led. There was a continued breach in regulation because the systems in place to monitor and manage the service were not effective. We served a warning notice and asked the provider to make improvements within a specific timescale.

At this inspection the required improvements had been made and the service had met the characteristics of Good in all areas. The overall rating is Good.

Follow up:

We will continue to monitor the service through the information we receive.

This inspection was unannounced and took place on 26, 27 June 2018 and 23 July 2018.

Scotia Heights is a care home that provides nursing care. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Scotia Heights is registered to provide a service for up to 60 people who have a neurological disability, enduring mental health, brain injury, stroke and early onset dementia. On the days of our inspection there were 52 people living in the home. The home is situated on three floors and divided into six units of which were accessed by a passenger lift.

We carried out an unannounced comprehensive inspection of this service on 7 and 9 February 2018. The provider was found to be in breach of regulation 17, Good governance. After that inspection we received concerns in relation to the safety and wellbeing of people who used the service. As a result, we undertook a focused inspection to look into those concerns. This report only covers our findings in relation to this topic. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Scotia Heights on our website at www.cqc.org.uk

At the previous inspection in February 2018, the service was rated ‘Requires Improvement.’ We carried out an inspection on 26 and 27 June 2018 and 23 July 2018. At this inspection we found concerns relating to care and support provided to people. We shared these concerns with the operation manager and the operation support manager who assured us that action would be taken to improve the service provided to people. On the third day of our inspection the provider had taken some action to improve the safety and welfare of people. The overall rating for this service is ‘Requires Improvement.’

The home has been without a registered manager since November 2017. This meant the provider was in breach of the conditions of their registration. 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. In the absence of a registered manager the home was being run by two interim managers who were supported by the operation support manager who informed us they would be applying to registered with the commission.

At this inspection we identified that improvements were needed to ensure the safe management of medicines. We found the risks to people were not managed effectively or safely and this compromised their wellbeing. When we returned on the third day to complete our inspection. The provider had taken some action to ensure people received their medicines as directed by the prescriber. The risk to people had been reviewed and some systems put in place to reduce the risk of potential harm to them.

Since our last inspection in February 2018, additional staff had been recruited to ensure people received consistency with the care and support provided. People could be confident that practices and systems in place would reduce the risk of cross infection. People had access to information about who to talk to if they had any concerns about abuse and staff were aware of their responsibilities of safeguarding people from the risk of potential abuse.

Since the last inspection visit the management team had changed. The provider’s governance was ineffective in assessing, monitoring and to drive improvements. However, the operation manager told us about systems and practices to assess and monitor the quality of service which had recently been implemented and as such we have not been able to assess the sustainability of these new systems. People who used the s

This inspection was unannounced and took place on 7 and 9 February 2018.

Scotia Heights is a care home that provides nursing care. 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.

Scotia Heights is registered to provide a service for up to 60 people who have a neurological disabilities, enduring mental health, brain injury, stroke and early onset dementia. On the days of our inspection there were 56 people living in the home. The home is situated on three floors and divided into six units of which were accessed by a passage lift.

At the previous inspection in March 2017, the service was rated ‘Requires Improvement.’ At this inspection we found that the provider had taken some action to improve the quality of service provided to people. However, there were still areas that required improvement. The overall rating for this service remains as ‘Requires Improvement.’

The home has been without a registered manager since November 2017. 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. In the absence of a registered manager the home was being run by a peripatetic manager. In this report we refer to this person as the ‘manager.’

The management of medicines needed to be improved to ensure people received their treatment as prescribed. People were at risk of not receiving consistent care and support due to the frequent use of agency staff who were unaware of their needs. However, we found that staff had been recruited safely. People may be discriminated against due to their disability and where their first language is not English. The provider’s governance was ineffective to identify the shortfalls we found and to ensure people received a safe and effective service.

Staff had access to risk assessments to support their understanding about how to care for people safely. The hygiene standards within the home were satisfactory. Systems were in place to learn from near misses to ensure people’s safety. People felt safe living in the home and staff were aware of their responsibility of safeguarding them from the risk of potential abuse.

People were cared for by skilled staff who were supported in their role by senior staff. The principles of the Mental Capacity Act were adopted in care practices to promote people’s human rights. People were supported to eat and drink sufficient amounts and had access to a choice of meals. The involvement of other healthcare professionals assisted in maintaining people’s physical and mental health.

People were cared for by staff who were kind and attentive to their needs. People’s involvement in their care planning ensured they received care and support the way they liked. People’s right to privacy and dignity was respected by staff and they were supported to maintain contact with people important to them.

People were supported by staff to pursue their interests. Complaints were listened to and acted on. People were given the opportunity to discuss their wishes regarding dying and end of life care.

People and staff were encouraged to be involved in the management of the home. People were complimentary about the new management team and were happy with the improvements made. The manager was supported in their role by the operations manager and the operations support manager. The managers had positive aspirations to drive improvements to ensure people received a good standard of care.

This inspection was unannounced and took place on 13 and 14 March 2017.

Scotia Heights provides accommodation and nursing care for up to 60 people. On the days of our inspection 55 people were living in the home. The provider offers a service for people who have a neurology disorder and brain acquired injury.

The home had a registered manager who was present for the 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.

Prior to our inspection we received information from a person who wanted their identity to be protected. They alleged there were insufficient staffing levels provided to meet people’s needs.

At this inspection we found that one unit was not sufficiently staffed to ensure people’s needs were met. The provider’s recruitment process entailed safety checks to ensure the suitability of staff. The risk of harm for some people was not always managed effectively. People were at risk of not receiving the appropriate support to take their prescribed medicines. People told us they felt safe living in the home. Staff were aware of their responsibility of sharing concerns of potential abuse with the registered manager to protect people from the risk of further harm.

People were cared for by skilled staff who were supported in their role by the management team. People confirmed they were able to make their own decisions. Staff were aware of the principles of the Mental Capacity Act and the Deprivation of Liberty Safeguards. People were supported by staff to eat and drink sufficient amounts and were assisted to access healthcare services when needed.

People received different care and attention depending on what unit they lived on. People were encouraged and supported to be involved in planning their care to ensure they received a service the way they liked. People’s right to privacy and dignity was respected by staff. Practices and access to appropriate equipment helped people to maintain their independence.

People’s involvement in their care assessment ensured their care preference was met. Some people were supported by staff to pursue their interests and hobbies. People were supported by staff to maintain contact with people important to them. People knew how and who to share their concerns with.

The provider’s governance was not entirely effective to ensure people’s needs were always met. People were encouraged to have a say in how the home was run. The home was managed by the registered manager who was supported in their role by the operation manager.

You can see what action we told the provider to take at the back of the full version of the report.

We inspected this service on 20 August 2015. This was an unannounced inspection.

The service was registered to provide accommodation and nursing care for up to 60 people. At the time of our inspection 47 people were using the service. People who used the service had physical and/or mental health needs. The majority of people who used the service were under the age of 65.

The service 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 and associated Regulations about how the service is run.

Our last inspection took place in September 2014. During that inspection a number of Regulatory breaches were identified. We told the provider that improvements were required to ensure people received care that was; safe, effective and well-led. At this inspection we found that those required improvements had been made.

At this inspection, we found that improvements were required to ensure that people who used a tracheostomy to help them breathe, were protected from the risks associated with them. Improvements were also required to ensure records relating to medicines were accurate and up to date.

With the exception of tracheostomy care, risks to people’s safety and wellbeing were assessed and planned for and the staff understood how to keep people safe. There were sufficient numbers of staff to meet people’s needs and staff received training that provided them with the knowledge and skills to meet people’s needs effectively.

Staff sought people’s consent before they provided care and support. When people did not have the ability to make decisions about their care, the legal requirements of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS) were followed. These requirements ensure that where appropriate, decisions are made in people’s best interests when they are unable to do this for themselves.

People were supported to access suitable amounts of food and drink of their choice and their health and wellbeing needs were monitored. Advice from health and social care professionals was sought and followed when required.

Staff treated people with kindness and compassion and people’s dignity and privacy was promoted. Information was given to people in a manner that enabled them to make choices about their care and the staff respected the choices people made.

People and their relatives were involved in the planning of their care and care was delivered in accordance with people’s care preferences. People were enabled to participate in leisure and social based activities that met their individual preferences.

People’s feedback was sought and used to improve the care. People knew how to make a complaint and complaints were managed in accordance with the provider’s complaints policy.

There was a positive atmosphere within the home and the manager and provider regularly assessed and monitored the quality of care to ensure standards were met and maintained.

We completed this inspection after we received information of concern that related to the care and welfare of people who used the service and the management of incidents.

As part of the inspection process we ask the following five key questions; is the service safe, effective, caring, responsive and well-led?

During our inspection we spoke with two people who used the service and one relative. We also spoke with eight members of staff and the clinical nurse manager. The registered manager was not present during our inspection.

We looked at four people’s care records to see if their records were accurate and up to date. We also looked at records relating to the management of the home. These included incident forms and staff rotas.

Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people who used the service, their relatives and the staff told us.

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

Is the service safe?

The service was not consistently safe. The provider could not assure people that their care was delivered in accordance with their agreed plans to protect their safety and welfare.

People’s personal and confidential information was not kept safe and secure. This meant there was a risk it could be lost or accessed without their consent.

Is the service effective?

The service was not consistently effective. The provider could not assure people that the advice of health care professionals was followed to enable their nutrition and hydration needs to be met.

Is the service caring?

People told us the staff were caring. We observed that staff provided care in an unrushed manner.

Is the service responsive?

We did not answer this question during this inspection because our inspection was focussed upon the areas of concern that had been shared with us.

Is the service well led?

The service was not consistently well led. Effective systems were not in place to check that people had received their care in accordance with their agreed plans. This meant the effectiveness and quality of the care was not being adequately monitored.

There was no effective system in place to ensure changes were made in response to incidents to reduce future incidents from occurring.

This was an unannounced scheduled inspection. As part of this inspection we also looked at the progress the home had made in meeting the concerns we had raised at our previous inspections. During the inspection we spoke with people who used the service, relatives, care and nursing staff, the acting manager and the clinical nurse manager.

We considered our inspection findings to answer the questions we always ask;

Is the service safe?

People who used the service had their needs assessed and risk assessments had been completed to reduce any risks to their health and well-being. Staff had received training in meeting people’s needs including safeguarding and recognition and reporting of abuse, manual handling and health and safety.

Staffing levels were sufficient to meet people's personal care needs, but the provider may find it useful to note that improvements to the deployment of staff should be considered.

Is the service effective?

People we spoke with told us, “I am okay here”. A relative told us, “Things are improving”.

People's care needs were assessed and plans were in place, including people’s nutritional needs. People who used the service had choices of meals at each meal time that reflected their specific needs. Meetings or food forums were held so that people could discuss the food provided and make comments on menus. The provider may find it useful to note there were some gaps in the food and fluid records. This meant that the people's nutritional intake was not always monitored effectively.

Is the service caring?

People told us they were supported by staff who knew them well. One person said, "They are lovely and nice". A relative told us, "The staff are fantastic, I have no concerns they treat my relative really well”. We observed that care staff spoke with people in a friendly and respectful manner.

We saw that people's preferences about their social care needs were recorded and the service provided a full programme of opportunities to ensure people were occupied and actively engaged. This meant people had stimulating and interesting things to do.

Is the service responsive?

The home had a complaints procedure. Information was available to people to tell them how to raise areas of concern. A relative told us, “I feel that I’m listened to when I have raised concerns”. People’s views of the service and those of their relatives or supporters were sought to ensure the service was meeting people’s needs. This meant that the provider was seeking people's views about their care to identify areas for improvement.

Is the service well led?

The service had a new manager. The manager was not registered with us (CQC). We were assured that they were in the process of submitting a registration application.

Systems were in place to monitor and audit the service, records of audits included medication and care records.

The views of staff were being sought, they received individual appraisal and supervision. Staff meetings were also arranged, but the provider may find it useful to note, they were not always held frequently.

At our previous inspection we found that the provider was not meeting the expected standards in one of the outcomes. We set compliance actions requiring the provider to make improvements to ensure the quality and safety of care.

We spoke with two relatives and five members of staff.

We found that improvements had been made regarding medication. There were safer processes in place for ordering, storing and administering medication.

We looked at the care records and saw that these have been improved. The care records contained detailed information which was relevant to the person to ensure that safe and appropriate care could be provided.

Whilst we were at the home we became concerned about staffing levels. The staffing rotas we looked at did not provide reassurance that enough staff were being allocated to safeguard the health and welfare of the people using services. A relative told us, "I don't feel that this is safe with all of these patients needing such complex and high level care".

We have asked the provider to provide us with a plan of action to improve the staffing ratio.

At our previous inspection, we identified that the provider was not meeting the expected standards in some of these outcome areas. We set compliance actions, requiring the provider to make the improvements required to ensure the quality and safety of care. At this inspection, we reviewed progress in the improvements needed and reviewed additional areas of care within the home.

We found that the staffing arrangements at the home had improved. We spent time on all of the five units at the home and found the care environment was relaxed and organised. Staff had time between care tasks to engage with people socially. One relative we spoke with told us, “Over recent months there has been a change for the better and right now I feel that the care my son receives is high quality.”

The arrangements for the assessment and planning of care ensured that people’s care and health needs were met. We found structured and detailed assessments and care plans were in place. Some records were not always fully completed or detailed to support decision making and the review of people’s needs. When people were unable to discuss or express what they wanted or agreed to, an assessment of what was in their best interests would be completed.

A programme of audits and checks were in place to support the on-going monitoring of the quality and safety of care. Improvements were needed to ensure the safe management of medicines in the home.

Following our last inspection in November 2012, we issued the provider and registered manager with warning notices, setting out what we required the provider to do and by when.

During this inspection, we spoke with two people who lived at the home and two visiting relatives. We also spoke with four members of staff. Relatives told us that the management team was more accessible than they had been. One relative told us that they had previously been concerned about a previous lack of continuity of staff. They said, “The new nurse in charge is a breath of fresh air, I have every confidence in them. In my opinion, the staff changes are for the better.”

Our inspection evidenced that changes had been made to address the shortfalls in the management of the home. The monitoring and management of the home ensured that day to day performance issues and concerns were now being identified and responded to. The provider had recruited a number of new permanent nursing staff. There was a clear rota management system in place where the use of agency staff was matched to people’s needs. Time for training was also being planned separately to the main duty rota. The home did not have a physiotherapist at the time of this inspection. We found that people’s physiotherapy needs had not always being met.

We observed care being delivered and saw very positive interactions between people using the service and staff. People were treated with respect when staff were answering questions and when they were supporting them with eating and with moving and handling.

Staff told us that many changes had been made since our visit in April 2011. Their training needs had been voiced and responded to with a range of courses to cover the many gaps identified. They said that care plans had been changed and all reviewed and there had been in-depth discussions with staff concerning the needs of people they were supporting. They told us that they now felt more confident in their work and better equipped to meet the complex needs of the people they were supporting.

The home did not know we were coming to complete our inspection. We talked with three people living at the home, four relatives and seven members of staff during our visit.

People living at the home and their relatives told us that life at the home was interesting and people were supported to maintain their interests and lead a full a life as possible. People were supported to be involved in all aspects of their life and, as much as possible, in decisions about their care or treatment. One resident told us that “the home has given me back my quality of life”. The main advocacy provider working with the home was positive about the working arrangements in place.

People and relatives told us how confident they were that the changes would be made to ensure good, quality care was provided. Two relatives told us they were asked to give their opinions and feedback on the care received. They also attended regular relatives meetings with the management team and felt that these enabled relatives to give their feedback and be involved in how the home delivered care.

We reviewed six care plans for people with a range of different physical and mental health needs. We found there was sufficient information provided to ensure staff could meet these needs. Risk management plans were in place to ensure staff had clear information to keep people safe. Where required, people’s needs were regularly monitored throughout the day and night. Daily notes provided a good overview of a person’s day.

The planning and allocation of staff did not always ensure continuity of care or ensure that there was enough staff, with the right skills and experience, to meet people’s needs. The current shift arrangements for staff meant that staff on duty may not always have access to up to date information on people in their care.

The training of staff reflected the needs of people living at the home. People and their relatives told us that they felt that staff were adequately trained to meet their needs. One relative told us that she had “every confidence” in the staff. Another relative told us that that they were “very happy with the quality of care.” One person we spoke with told us “Care staff look after me well – know what I need and like.”

The monitoring and management of the home did not always ensure that day to day performance issues were identified and responded to. During our visit, we observed at different points in the day staff on duty not fully engaged with providing care and support. We identified that delays in the review and reassessment of care needs and risks following incidents placed vulnerable people in one area of the home at risk of harm.

On our recent visit to this service we spoke with people using the service and staff. We observed care being given and saw good examples of positive, supportive and professional interactions between staff and people using the service.

People confirmed this in our discussions with them. They told us that they were treated with respect and dignity by staff when being supported in personal care tasks.

On the day of the visit we saw that staff interacted well with the people living on unit 2 and unit 4.

We saw that staff were available for people who required close observation thus meeting their needs.

We did not speak with the people using the service during our visit.

We looked at care notes and spoke to staff to determine people’s experiences whilst using the service. We saw that there were times when staff did not have the right skills or knowledge to deal with the people who were displaying aggressive or challenging behaviour.

At our last inspection, we set compliance actions to address issues identified in the management of staffing and monitoring of the home. During this inspection, we spoke with two people living at the home and two relatives. We also spoke with seven members of staff.

The provider still did not have a satisfactory system in place to protect people living at the home from the risk of harm. The monitoring and management of the home still did not ensure that day to day performance issues and concerns were always identified and responded to. Relatives we spoke with expressed their concerns about how well the provider was listening to their views and experiences.

The planning and allocation of staffing did not ensure there was always enough staff, with the appropriate skills and knowledge, to safeguard the health and welfare of the people who used the service. The provider was more frequently using agency staff to try and meet assessed nursing staff needs across the home. The provider could not provide evidence to support that the skills and experience of agency nurses had been satisfactorily addressed with the supplying agency.

One person told us that, “Some staff very good but they never have much time.” A relative told us that, “The girls are brilliant but you have to search for a nurse.” This relative told us they had general concerns about the competency and skills of new nursing staff to meet their relative’s specific needs.