This inspection took place on 13, 14 and 19 of November 2018 and was unannounced.

The Heights is a nursing home. People in nursing homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission regulates both the premises and the care provided. Both were looked at during this inspection.

The Heights is registered to provide nursing and residential care for up to 90 adults with a range of needs including younger adults living with a physical or learning disability and older adults with a range of needs including dementia, epilepsy and diabetes. Younger adults had complex care needs and lived in a separate accommodation called Downley Lodge, which was adjacent to the main building. Downley Lodge had its own staff team and entrance.

At the last inspection we rated the service as outstanding. At this inspection we found that the service remained outstanding overall. The service remained outstanding in well led and had improved from good to outstanding in effective. The service the service no longer meets the criteria for outstanding in responsive and is now good in responsive.

The home had a registered manager in post. 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.

There was an extremely positive culture at the home because staff put people at the heart of their practice. Staff provided outstandingly effective care as they were highly skilled, dedicated and passionate in their approach. People received highly individualised care as staff were committed to cultivating a thorough understanding of people’s health, wellbeing needs, social histories, important relationships and preferences. Staff treated people as individuals, celebrated their life histories and enabled them to access meaningful experiences.

The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.

The registered manager encouraged and supported staff in their training and career development. Staff completed a comprehensive induction, the Care Certificate and training specific to the needs of people living in the home. The registered manager facilitated training opportunities for staff and continually reviewed their development through a supervision system. It was clear they believed in the abilities and potential of their staff as without exception, staff members told us they felt incredibly well supported. All departments of the staff team were valued and were included in daily handover meetings. This helped staff maintain a detailed oversight of people’s needs and of service developments and changes.

The chef took a collaborative approach to menu planning and held regular meetings with people and their families to ensure foods were nutritious and enjoyable. People at risk of malnutrition were provided with immediate support to maintain a healthy weight.

The home was light, spacious and extremely well decorated and contained furniture and possessions from people’s own homes as well as quiet seating areas with objects of interest. This provided attractive, appealing spaces for people and their families to relax in.

Staff were highly skilled at liaising with professionals from different agencies to provide people with timely support. They worked in partnership with professionals to ensure people received the highest possible standards of care.

Without exception, staff told us they were given support by the registered man

This inspection took place on 14,15 and 21 January 2016. It was an unannounced visit to the service.

We previously inspected the service on 22 May 2014. The service was meeting the requirements of the regulations at that time.

The Heights provides care for up to 90 people with a range of needs, including younger adults with learning disabilities, nursing care and care of people with dementia. Eighty three people were being cared for at the time of our visit. Younger adults had a mix of complex care needs and lived in accommodation which was separate to the main home, called Downley Lodge. This had its own entrance, facilities and staffing arrangements.

The service had 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 received positive feedback about the service. Comments from people included “I did not want to live in a care home, and found it difficult to settle…I am so happy now, I am cared for, and looked after very well,” “Staff know all their residents very well and what they like,” and “I don't think we could find a better place than this.”

People were protected from the risk of harm at the service because staff had undertaken training, to recognise and respond to safeguarding concerns. Staff had a good understanding about what safeguarding meant and how to report it.

People’s medicines were handled safely and were given to them in accordance with their prescriptions. People’s GPs and other healthcare professionals were contacted for advice whenever necessary.

There were enough staff to meet people’s needs. They were recruited using robust procedures to make sure people were supported by staff with the right skills and attributes. Staff received appropriate support through a structured induction, regular supervision and an annual appraisal of their performance. There was an on-going training programme to provide and update staff on safe ways of working. Several staff were also involved with nationally-recognised courses such as Business and Technology Education Council (BTEC) awards.

People were supported to take part in a wide range of activities. This included enabling younger adults to access the community and pursue hobbies, such as supporting the local football team.There were creative themed displays around the building to help engage with people with dementia and to reminisce. Staff had gone above and beyond the call of duty to fulfil some people’s wishes and dreams.

The building was well maintained and kept in a safe condition. Evacuation plans had been written for each person, to help support them safely in the event of an emergency.

The registered manager took part in various accreditation and research schemes to help improve the quality of people’s care. There were clear visions and values for how the service should operate and staff promoted these.

The provider regularly checked quality of care at the service through visits and audits. These showed the service was performing well. Records were maintained to a good standard and staff had access to policies and procedures to guide their practice.

When we visited the service on 28 and 29 January 2014, we had concerns about how four standards were managed at the home - care and welfare of people who use services, cleanliness and infection control, management of medicines and records. We set compliance actions for the provider to improve practice. The provider sent us an action plan which outlined the changes they would make to become compliant. We used this visit as an opportunity to check that sufficient improvements had been made.

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 caring?

• Is the service responsive?

• Is the service safe?

• Is the service effective?

• Is the service well-led?

This is a summary of what we found -

Is the service safe?

We found there were effective systems in place to reduce the risk and spread of infection. We saw improvements had been made to infection control practice at the home. This included use of wheeled trolleys to transport clinical and other waste out of the building. This reduced the likelihood of contaminated waste coming into contact with floors and other surfaces. Training had taken place so that more staff had the necessary skills and knowledge about good infection control practices. We saw waste bags were sealed with plastic ties to prevent the contents spilling and spreading infection. We noted covered trolleys were in use to control hazards associated with soiled or contaminated laundry and reduce the risk of infection.

People we spoke with told us the home was kept clean. One person said “It’s always kept nice and clean,” another said “Someone comes and cleans my room every day.” Housekeeping staff told us they were provided with the materials they needed to carry out their work effectively. They said they were informed when people had infections, such as MRSA, and described the precautions taken to prevent cross infection. This showed staff followed appropriate guidance in relation to infection control practice.

People who used the service were only deprived of their liberty when this had been authorised by the Court of Protection, or by a Supervisory Body under the Deprivation of Liberty Safeguards (DoLS). We read documents which related to a recent authorisation by the local authority. This showed the service had made an appropriate referral where someone wanted to return to their former home. The manager told us training was being arranged for staff, to provide them with the skills and knowledge to understand about mental capacity and DoLS.

Improvements had been made to medication practice. This included completion of training by all staff who handled medicines, better safeguards on the use of “as required” medications and daily audits of controlled drugs. This ensured medicines were handled safely and appropriately at the home.

We looked at a range of records as part of this visit, including care plans, risk assessments, training records and medication administration records. We found improvements had been made at the home to ensure records were up to date, well maintained and fit for purpose. The manager was able to locate all records we requested promptly. Sensitive information, such as staff files, was kept securely with access restricted to authorised persons only. This ensured confidential information was stored safely and appropriately.

Is the service effective?

We looked at a sample of care plans and other records in two different parts of the building. These showed that people’s needs were assessed and care and treatment was planned and delivered in line with their individual care plan. Each care plan provided a comprehensive account of the person’s needs and how these were to be met. Information had been kept up to date and reviewed regularly. This ensured changes to people’s circumstances were identified promptly and their care amended as necessary.

Is the service caring?

Two visitors we spoke with were pleased with the overall standards of care. One told us their relative was “Well cared for and happy here. Staff look after him and they call the doctor if they’re worried.” We spoke with six people and observed care where people could not express their views to us. People were generally satisfied with their care. Comments included “There’s a good range of activities. I like to go to all of them,” “Staff are friendly and respectful. They have a laugh with me,” “My family can come any time and they’re made welcome,” and “I’m settled and well looked after. The food is good and there’s always lots of vegetables, which I like.”

We observed staff were mostly attentive to people and provided reassurance where people showed signs of distress. We overheard one incident where a member of staff spoke harshly to a person. When we mentioned this to the manager, action was taken straight away to look into what happened and prevent recurrence.

Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. Risk assessments had been written for a range of activities and situations. For example, use of bed rails, the likelihood of developing pressure damage, risk of malnutrition and assisting people with moving and handling. These assessments had been kept up to date and information was reviewed on a regular basis. Support plans were put in place where people were assessed as being at risk. This helped reduce or control the potential for people to experience harm.

Is the service responsive?

Records showed people had access to healthcare professionals and specialist advice, such as Parkinson’s Disease nurses and tissue viability nurses. Staff kept records of the outcome of any medical visits or appointments people had. These provided an account of any recommended courses of treatment and follow up action required. We saw staff were prepared for the GP’s round on the day of our visit. For example, the relevant care plans and medication records were to hand for the doctor to refer to. Staff were able to answer any questions the doctor had about people’s health and updated them accordingly. The doctor described how they worked collaboratively with the home to meet people’s healthcare needs and said they had been impressed by some of the staff. They said they did not have any concerns about people’s care and welfare.

Is the service well-led?

The provider had a system of carrying out annual quality assurance audits of its services and themed audits throughout the year. Regular monitoring visits were made by the home’s line manager, who was the divisional nursing lead for the organisation. Areas which needed improvement were identified as part of these processes and actions were taken to remedy matters.

There was an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who used the service and others. Risk assessments were in place, such as personal emergency evacuation plans, moving and handling assessments and nutritional screening. These had been kept under regular review to ensure information was correct and reflected people’s changing needs.

We were satisfied the provider had made sufficient improvements in the areas where we previously had concerns and was now compliant.

We spoke with five people using the service. One person told us, ''It's very good here. They do things properly.'' Another said, ''They look after you if you're unwell.'' One person told us they were being kept comfortable. They confirmed actions in their care plan were being taken to keep them well.

People we spoke with said staff responded to calls bells within reasonable amounts of time. One said, ''It varies, sometimes they are very busy.''

Some people that we met were able to speak with us and share their experiences of living at The Heights. Many of the people at the service have dementia and were unable to communicate their experiences. We used a tool called the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

Some of the feedback we received showed that people were supported in promoting their independence and community involvement. One person that we spoke with told us they were being supported to move to more independent accommodation later in the year. They said there was an issue that they did not understand and staff reassured us that an advocate was involved, which the person confirmed.

We were shown photographs which staff had put on the wall in one of the lounges, to make an eye catching display. This showed people involved in a range of activities from cooking, being out in the community and together with their friends. A person that we spoke with said they were happy with the current activities available to them.

We observed staff coming on duty and coming over to say hello to people, asking how they were and taking an interest in them.

We saw that any personal care was carried out in private areas of the building, to promote people's privacy and dignity. We heard staff asking one person if they would like to put some socks on their bare feet, which they declined. Another member of staff was heard asking someone if they would like to be helped to move from a wheelchair into an armchair, so that they could be more comfortable. Their wishes to remain in the wheelchair were respected.

Two people who visit the service contacted us and were critical of standards of care. They highlighted inconsistencies in records of personal care, such as completion of charts, and standards of nursing care.

We visited the home over two days. We spoke with fourteen people who lived there, nine relatives, fifteen staff and the manager. We observed care and support, read eight care plans and looked at other records for specific information.

People told us the staff were “lovely” with one person telling us “they are good staff here, they come to help me when I need it.” A relative told us “it’s the best it can be if they need to be in somewhere.”

We found not all people who lived there were receiving the care and support they required to meet their needs.

People were safe from abuse as the staff were aware of the signs to look for and people told us they would report any issues they had.

Relatives told us the home was “always clean.” We saw there were some practices which meant people may be at risk from the spread of infection.

People received their prescribed medicines.

Some people who lived at the home and their relatives told us there were not always enough staff to meet people’s needs. We found this was under review by the organisation.

Staff we spoke with told us they felt supported by their manager.

People who lived there and their relatives knew how to complain. Where complaints had been made these had been investigated and measures taken to prevent recurrence.

The records regarding assessments of people’s risks, needs and how to meet them did not provide sufficient information for staff. Records of staff training were not up to date.