The Highgate Care Home

The Highgate Care home is a residential care home providing personal and nursing care to people with complex physical and cognitive support needs at the time of the inspection. The service can support up to 52 people in four separate units with their own communal areas and facilities. At the time of our inspection 41 people were living at the home.

People’s experience of using this service and what we found

At our last inspection people with complex physical needs were using a lift situated in a service adjoining the home as the lift at the home could not accommodate stretchers and some specialist wheelchairs. The provider had taken action to address this and work on installing a new lift has now commenced.

People had person centred care plans and risk assessments. These were up to date and included information about their needs and preferences along with detailed guidance for staff on how to provide effective and responsive support. Where people’s needs had changed, their care plans and risk assessments had been reviewed and updated immediately.

Improvements had been made to the food provided to people on soft or pureed diets due to choking risks. Staff had received training on modified diets and were required to taste food and check if the texture is suitable before offering it to people. People told us they enjoyed the food and were offered choices.

People’s medicines were stored and administered safely. Medicines were administered by nurses and senior care workers. The records of medicines administration had been completed appropriately and guidance was in place for medicines that were provided on an ‘as required’ basis. Some people who were unable to swallow received medicines via a feeding tube. Their records showed that such medicines were administered following professional guidance. Staff administering medicines via a tube feed had received training.

People were protected from the risk of harm or abuse. Staff members had received safeguarding training and knew what to do if they had concerns about a person’s safety. The home’s records of safeguarding concerns showed that appropriate actions had been taken to reduce the possibility of similar concerns arising in the future. Safeguarding concerns had been reported to the local authority and the Care Quality Commission (CQC).

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Staff were recruited safely and received the training and support they needed to do their job well and to effectively meet people's needs.

The home’s quality monitoring systems showed regular audits had been carried out. These included audits of care plans and risk assessments, medicines, infection control, and safety at the home. Actions had been taken to address any concerns identified by these audits. The provider made unannounced monitoring visits to the home. The registered manager and deputy manager undertook unannounced monitoring visits at night. This ensured the provider and the registered manager were able to maintain safe practice at the home.

Infection prevention and control measures and practices were in place to keep people safe and prevent people, staff and visitors catching and spreading infection.

The registered manager was supported by a deputy manager and a team of nurses and senior care workers. Staff, people and their family members told us they were satisfied with the management of the home.

Staff engaged with external health and social care professionals to ensure people’s needs were met. They held regular meetings with a multi-disciplinary team of professionals to discuss and address people’s immediate and ongoing needs. A local GP visited the home twice weekly.

People and relatives spoke positively about the care and support provided by staff.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was Good (published 7 May 2021).

Why we inspected

The inspection was prompted in part by notification of an incident two years ago, following which a person using the service died. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk of death or injury caused by choking. This inspection examined those risks.

This report only covers our findings in relation to the Key Questions Safe, Effective, and Well-led.

The rating from the previous comprehensive inspection for the key questions not looked at on this occasion was used in calculating the overall rating at this inspection. The overall rating for the service has changed from Requires Improvement to Good. This is based on the findings at this inspection. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Highgate Care Home on our website at www.cqc.org.uk.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The Highgate Care home is a residential care home providing personal and nursing care to 36 people with complex physical and cognitive support needs at the time of the inspection. The service can support up to 52 people in four separate units with their own communal areas and facilities.

People’s experience of using this service and what we found

The home environment was clean and well presented with ample space and lighting to enable easy movement. However, at our last inspection the provider advised that installation of a second, larger lift was planned. At this inspection we found people with complex physical needs continued to use a lift situated in a service adjoining the home. We have made a recommendation that the provider continues to improve accessibility and the quality of the environment to better meet people's needs in relation to their disabilities.

People’s care plans had improved since our last inspection of the home. They were person-centred and included guidance for staff on ensuring that people’s individual needs were met. Where people’s needs had changed this had led to an immediate update of their care plans. Individual risk assessments for people had been regularly reviewed and updated where required.

People’s medicines were stored and administered safely. The records of medicines administration had been completed appropriately. Some people who were unable to swallow received medicines via a tube feed. Their records showed that such medicines were administered following individualised professional guidance.

People were protected from the risk of harm or abuse. Staff members had received safeguarding training and knew what to do if they had concerns about a person’s safety. The home maintained records of safeguarding concerns. These showed that appropriate actions had been taken to reduce the possibility of similar concerns arising in the future.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Staff were recruited safely and received the training and support they needed to do their job well and to effectively meet people's needs.

During the COVID-19 pandemic a regular programme of socially distanced activities had taken place at the home. These were delivered via video links where the activities providers were unable to personally attend the home. Improvements had been made to the records of ‘in-room’ activities for people unable to attend group activities. We saw that regular one-to-one activities and staff engagement had taken place. Arrangements had been put in place to enable family members and friends to safely visit people living at the home.

Improvements had been made to the home’s quality monitoring systems. These were now designed to be more effective in identifying concerns and making improvements when required.

Suitable infection prevention and control measures and practices were in place to keep people safe and prevent people, staff and visitors catching and spreading infection.

The registered manager was supported by a team of managers and nurses. Staff, people and their family members told us they were satisfied with the management of the home.

Staff engaged proactively with external health and social care professionals to ensure people’s needs were met. They had regular meetings with a multi-disciplinary team of professionals to discuss and address people’s immediate and ongoing needs.

People and relatives spoke positively about the care and support provided by staff.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was Requires Improvement (published 1 November 2019).

Why we inspected

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Effective, Responsive and Well-led.

The rating from the previous comprehensive inspection for the key question not looked at on this occasion was used in calculating the overall rating at this inspection. The overall rating for the service has changed from Requires Improvement to Good. This is based on the findings at this inspection. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Highgate Care Home on our website at www.cqc.org.uk.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The Highgate Care Home is a residential care home providing personal and nursing care to 31 people with complex physical and cognitive support needs at the time of the inspection. The service can support up to 52 people in four separate units. People living at the home are provided with 24-hour care and support.

People’s experience of using this service and what we found

People told us they felt safe and that the staff who supported them were kind and respectful. Family members told us that they had not always been satisfied with the support that their relatives received but they did not currently have any concerns.

People's care and plans and risk assessments had been updated in areas such as medicines and nutrition. However, other information contained in people’s care records had not been used to update care plans and risk assessments. For example, the information about people’s communication needs and support contained within their care plans was not always consistent with the information recorded in their reviews. A plan had been put in place to ensure that care plans and risk assessments were updated and maintained in the future.

People’s medicines were stored and administered safely. The provider had addressed concerns about medicines raised during recent health and social services monitoring visits. Staff were liaising with the local pharmacy service to improve the quality of the support they provided.

Improvements had been made to ensure that people who required specialist nutritional support in relation to swallowing difficulties received suitable nutrition and hydration. People’s care plans had been updated to reflect current good practice in relation to their nutritional needs.

Staff members received regular training to support them in carrying out their roles. However, we found that staff had not always received regular supervision from their manager during the past year. The provider recognised that staff supervisions had not taken place regularly, and when we inspected they had commenced a regular programme of supervision for all staff.

Systems were in place to assess and monitor the quality and delivery of care to people. However, these had not always identified or addressed failures in people’s care and support. A quality improvement plan had been put in place to address these and some improvements had been made with planned actions in place to address other concerns.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Staff were caring and treated people with dignity. People’s differences including cultural and religious needs were understood and respected by staff.

Staff understood the importance of social interaction. People were supported to maintain the relationships they wanted. A daily activity programme took place at the home that included music therapy, exercise sessions, flower arranging, arts and crafts and discussion sessions. Social events included the celebration of religious festivals and birthdays. Activities were also provided to people who were unable to leave their rooms. For example, a music therapist and physiotherapist visited people to provide one to one sessions following their group activities. The activities co-ordinator also visited people in their rooms to ensure they received activities and social engagement. Some people had been supported to identify their individual wishes in relation to hobbies and interests and staff had supported them to achieve these.

Staff knew what their responsibilities were in relation to keeping people safe. Staff knew how to recognise and report any concerns they had about people's welfare and how to protect them from abuse.

The home was clean and safely maintained.

The interim manager showed effective leadership. Staff felt supported. Staff and family members told us that they were satisfied with, and well informed about, the changes the management team had put in place.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was Good (published 26 July 2018).

Why we inspected

The inspection was prompted in part due to concerns received about medicines, nutritional support, care plans and failures in relation to the Mental Capacity Act 2005. A decision was made for us to inspect and examine those risks.

We have found evidence that the provider needs to make improvements. Please see the Safe, Effective, Responsive and Well-led sections of this full report.

The home is set out across four floors or 'units' with lift access between each. Each floor had a communal lounge and dining area which we saw being used from time to time. A general communal dining area and activity space was provided on the lower ground floor of the building. At the time of our inspection there were 49 people living at the home, some of whom received care in their rooms due the severe and profound nature of their disabilities.

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 last inspected this service in May and June 2017 when the home was rated as 'Requires Improvement'. At our last inspection we identified failures in the management and recording of people’s medicines. We also found that these failures had not been identified and addressed by the quality monitoring systems in place at the home.

At this inspection we found that actions had been put in place to address our concerns. People’s medicines were effectively administered, managed and recorded. Regular medicines audits had taken place and we saw that stock counts of medicines were accurate.

Risks associated with people's care and support needs had been identified. Individual risk assessments were in place with along with guidance for staff on how to safely manage these risks.

People told us they felt safe. Procedures and policies relating to safeguarding people from harm were in place. Staff members had completed training in safeguarding adults and demonstrated an understanding of their roles and responsibilities in identifying and reporting safeguarding concerns.

We saw evidence of a comprehensive staff induction and on-going training programme. Staff had regular supervisions and annual appraisals. Staff members were safely recruited with necessary pre-employment checks being carried out.

People were given choices during meal times and their needs and preferences were addressed. People's weight was recorded regularly and action was taken should people lose weight significantly.

The registered manager demonstrated a good level of understanding of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Assessments of capacity were in place and applications to the relevant local authority had been made for DoLS authorisations had been made where appropriate.

We saw that interactions between staff and people were friendly, caring and supportive. Some people were unable to leave their rooms due to the complex nature of their disabilities and we observed that staff members checked on their welfare regularly and engaged them in discussion.

There was a wide range of activities taking place at the home. People spoke positively about these. Support for people to participate in individual activities was provided, including for people who were unable to leave their rooms.

A complaints procedure was in place which was displayed for people and relatives. People knew how to make a complaint.

Staff, residents and relatives' meetings were held regularly and surveys were completed by people and relatives. The home undertook regular monitoring of quality and safety and we saw that actions arising from these had been addressed.

The home liaised regularly with other health and social care professionals on behalf of people. A visiting health professional told us that there were effective arrangements in place to ensure that people’s healthcare needs were met.

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 last inspected this service in April and May 2015 and the service was rated as ‘Good’.

At this inspection we identified concerns with how the service managed medicines. Medicines were not being managed safely. We found five instances of where people were not administered their prescribed medicines despite nursing staff having recorded that they had. ‘As needed’ or ‘loose’ medicines were not consistently monitored to assure accurate stock levels.

People and relatives that we spoke with highlighted concerns around the low staffing levels within the home. Appropriate level of need assessments had been completed, which determined the staffing levels. We observed there to be sufficient staff available to support people.

Risks associated with people's care and support needs had been identified and these had been assessed giving staff instructions and directions on how to safely manage those risks.

People told us they felt safe. Procedures and policies relating to safeguarding people from harm were in place and accessible to staff. All staff had completed training in safeguarding adults and demonstrated an understanding of the types of abuse to look out for and how to raise safeguarding concerns.

Appropriate checks had been made to ensure the premises were safe.

We saw evidence of a comprehensive staff induction and on-going training programme. Staff had regular supervisions and annual appraisals. Staff were safely recruited with necessary pre-employment checks carried out.

People were given choices during meal times and their needs and preferences were taken into account. Nutritional assessments were in place, which included the type of food people liked and disliked. People's weight was recorded regularly and action was taken should people lose weight significantly.

The registered manager and staff demonstrated a good level of understanding of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). The registered manager had submitted applications to the local safeguarding authority for each person who required an authorisation to ensure that people were legally being deprived of their liberty which was in their best interest.

We observed caring and friendly interactions between management, staff and people who used the service and people spoke positively of staff and management.

A complaints procedure was in place which was displayed for people and relatives. There was an incident and accident procedure in place which staff knew and understood.

Staff, residents and relatives meetings were held regularly and surveys were completed by people and relatives.

People, relatives and staff spoke positively of the current management team. Quality assurance processes were in place to monitor the quality of care delivered.

We identified a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This breach related to safe medicines management. You can see what action we told the provider to take at the back of the full version of the report.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, 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?

Staff worked in cooperation with health and other professionals to ensure that the service had good practices in place to reduce the risks to people from falls. The service had an action plan they were working towards to improve these practices.

CQC monitors the implementation of the Deprivation of Liberty Safeguards (DoLS), which apply to people who live in care homes. While the service did not have anyone subject to DoLS for their own safety, the manager and deputy manager showed a good understanding of the process used to apply for DoLS. Staff had been trained in DoLS, and guidelines were available for staff should they be faced with a decision of this nature.

We found that the procedure followed for allowing visitors into the home left people at risk when we visited early in the morning.

Is the service effective?

We saw care plans were reviewed regularly by the nursing staff. At our previous inspection we had found that care plans were not always signed as being agreed by the person or someone acting on their behalf. At this inspection we found this had improved and all care plans we looked at were signed and dated as being agreed.

Care and treatment was planned and delivered in a way that was intended to ensure

people's safety and welfare.

Is the service caring?

People who used the service had some different views about staff although all were generally positive. One person told us 'they put clean covers on my bed every day, I told them it's not a hospital, they don't have to, but they insist.' Another person told us 'the staff are always gentle, I swear at them when they're not so they know by now' and a visiting relative said 'staff talk to my relative about what is going on while they support them, they talk about what is on the radio or out the window, current affairs, they don't just ignore them or talk amongst themselves which is very nice.'

People told us that they enjoyed the activities available at the home although some people preferred not to join in.

Is the service responsive?

At our previous inspection we saw that the provider had just introduced a new care planning format. We found that this had now been introduced across all the care plans that we looked at. This format provided a framework for staff to make full assessments of people prior to admission and to develop a care plan and risk assessments.

People's religious, cultural and personal diversity was recognised by the service. The manager informed us that most of people using the service were of Christian faith. The service had links with local places of worship and we were informed that advice was sought if the staff team needed to check how to ensure people's cultural and religious identity were respected.

Is the service well-led?

The provider kept records, which we viewed, showing which training staff had completed, when refresher training was due in core skills and plans to include additional training in specialised areas. Each member of staff had an annual appraisal record which had just been started for the current year in May 2014.

The provider has a system for monitoring the quality of care. We were provided with a copy of the most recently published customer satisfaction survey from August 2013. This showed that most people rated the service as either very good or excellent in most areas.

The provider had improved its quality assurance checks since our last inspection and we felt that the management team was now better equipped to pick up on issues and to respond promptly. There was evidence that people were being consulted in detail about their care.

People who used the service benefitted from a range of group activities. People who could not leave their rooms due to ill health received one-to-one visits to carry out activities of interest to them. Two people spoke very highly of the music therapy sessions.

We saw evidence that staff members were, for the most part, up-to-date with mandatory training, but little dementia training had been made available, although some people who used the service had needs in this area.

We found that care was generally of good quality, but there were inconsistencies and these were not being addressed effectively.

We found that people who used the service expressed their views and were involved in making decisions about their care. People we spoke to commented that where staff assisted them with their personal care this was done in a respectful manner that reflected their preferences and promoted their dignity. We found that people's needs were assessed and care and treatment was planned and delivered in line with their individual care plan. People we spoke to told us that they enjoyed the activities on offer and that they could choose whether or not to participate in a particular session. People who use the service told us that they enjoyed the meals provided and felt safe in the home. People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines. We found that there were enough qualified, skilled and experienced staff to meet people's needs.