Hill House - Care Home with Nursing Physical Disabilities

Hill House - Care home with Nursing Physical Disabilities is a residential care home providing personal and nursing care to up to 24 people. Each person had their own en-suite bedroom and access to communal lounges and adapted bathrooms. Separate to the main building is a bungalow which provides activities and facilities for people to use. At the time of our inspection there were 24 people using the service.

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

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic.

Right Support :

People’s support plans were developed through personal centred support planning tools. These were up to date and reflected the person’s support needs, wishes and preferences. Assistive Technology was available to support people’s independence for those who wishes to engage with this.

People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible. Policies and systems in the service supported this practice. The design and layout of the property made it accessible for a person with a physical disability, with bedrooms personalised to the individual.

Right Care:

People were supported by staff who knew them well and who had a good understanding of their needs. Staff received the training they needed to support people effectively. Additional training was planned to ensure staff had the appropriate skills to support people with a learning disability. People told us they were happy with the support staff provided.

Right Culture:

The service was well-led and staff were supported by the management team and registered manager. The registered manager had systems in place to protect people from abuse, with internal and external processes in place for reporting concerns.

Staff told us they felt supported within their roles. People told us they felt safe with the support they received and could speak to the registered manager if they had a problem.

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 13 December 2019).

Why we inspected

We received concerns in relation to staffing levels, aspects of health and safety and the management of people’s nursing care needs. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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 COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service remains good.

We found no evidence during this inspection that people were at risk of harm from this concern. Please see the Safe and Well-Led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Hill House - Care home with Nursing Physical Disabilities on our website at www.cqc.org.uk.

Follow up

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

Accommodation is provided in one adapted building. Additionally, there is separate building which provides activity and therapy facilities and there is a sensory garden.

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

We received feedback from people using the service and staff that staffing levels had not always been sufficient which meant that sometimes people had to wait longer than usual for support and that there was a high use of agency staff. The manager was aware of these concerns and staffing levels had recently been increased. On the second day of the inspection the increased level was in place and staff reported that this had made a difference. Additional nursing staff had been recruited and interviews were planned in the next few days for care staff which would reduce the level of agency staff used.

People told us they felt safe living at Hill House. They were protected from abuse and avoidable harm by staff who were appropriately trained in recognising signs of abuse and were aware of the steps to follow should the need arise. Medicines were managed and administered by trained and competent staff and people received their medicines as prescribed. Measures were in place to control and prevent the spread of infection.

People were treated fairly and without discrimination, including characteristics protected by law. However, one person felt their religions needs were not being fully met. We have made a recommendation about reviewing people’s cultural and religious needs. Staff received ongoing training relevant to their roles. People were supported to maintain their health and wellbeing with access to a range of health care professionals. The environment was spacious and fully adapted to meet people’s needs.

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.

Warm and trusting relationships had developed between people and staff. Staff were caring and people were at ease in their company. People told us they were treated with dignity and respect and their privacy was respected.

There was an ongoing programme of activities and people pursued their own interests. However, some people felt the activities were no longer suitable for them due to their changing needs. We have made a recommendation about reviewing activity provision.

People and staff spoke positively about the manager. The manager was clear about their role. Changes of management at regional and service level had impacted upon some areas previously highlighted for improvement. During the inspection, the quality business partner provided a detailed service improvement plan which incorporated areas identified during the provider’s quality assurance checks and feedback provided throughout the inspection.

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

Rating at last inspection and update

The last rating for this service was Requires Improvement (published 18 December 2019).

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

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.

At our last inspection we identified that the registered provider was in breach of regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 relating to safe care and treatment, safeguarding people from abuse, staffing and good governance.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions Safe, Effective and Well-led to at least good. During this inspection we found that although we could see that progress had been made in some areas, further improvement was still required in others. We found that the registered provider was in continued breach of regulation 12, safe care and treatment but was no longer in breach of regulations relating to staffing, safeguarding people from abuse and good governance.

Hill House is a ‘care home’. 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. Hill House can provide accommodation for up to 23 people.

There was a registered manager in post however they were not present during the inspection and an interim manager had been appointed.

We found shortfalls in the safe and proper management of medicines. People’s associated risks were assessed however documentation and outcomes were confusing as two types and differing ratings were used.

We made a recommendation that the provider revisits an element of the service improvement plan with regard to consistent documentation relating to agency staff.

Accidents and incidents were recorded however we saw that managerial oversight and investigation needed to be more robust. We discussed our findings with the interim manager during the inspection and they developed a flow chart providing additional guidance to staff which included the need for regular managerial oversight.

Staff had received training and were able to demonstrate understanding of the procedures they would follow to protect people at risk of harm from abuse. People living at Hill House told us that they felt safe.

The environment was spacious, visibly clean and free from malodours. We checked safety certificates and found them to be in order. Regular fire drills were carried out. People had a personal evacuation plan (PEEP) detailing the support they would need in the event of an emergency and a business continuity plan was in place.

During the inspection, staffing levels appeared sufficient to meet people’s needs however we received varied views about this from people using the service and their relatives. People’s dependency levels were linked to an electronic system used to calculate staffing levels. Staff recruitment procedures were safe. Staff were supported and received the training they needed to carry out their roles effectively.

We saw that applications had been submitted as required where people were deprived of their liberty as required by the Mental Capacity Act 2005 (MCA). However, we saw that assessments of people’s capacity were carried out routinely for some decisions and this was not in line with the principles of the MCA.

Staff were inventive in achieving positive outcomes for people living at Hill House. Care was person-centred and people were treated as individuals. There was a programme of work underway to improve the quality of care plan documentation. The mealtime experience was observed to be positive and food was nutritious and of a good quality.

Conversion of a bungalow had been completed since our last inspection and provided activity and therapy facilities. The facilities would benefit from a covered pathway enabling them to be more accessible in bad/cold weather. Some people felt that there was not enough to do.

People were supported to access a wide range of health professionals and staff were dedicated in supporting people’s health and well-being. We saw that warm, friendly and trusting relationships had been developed between the people living at Hill House and the staff supporting them.

There was a policy and procedure in place to manage and respond to complaints. We received comments which indicated that complaints/concerns were now dealt with although this had not always been the case previously.

The interim manager and staff engaged with the inspection process and responded positively when queries were raised. We saw that initially progress towards completion of the service improvement plan had been slow but that this had more recently improved with the appointment of the interim manager and regional management changes. We spoke with the regional manager by telephone following the inspection and they informed us of their plans and commitment to achieve further improvements at Hill House.

The service was previously inspected in May 2015. The registered provider was complying with all regulations at that time..

Hill House is a care home providing both accommodation and nursing and personal care for up to 23 adults who have a physical disability. The service is provided by Leonard Cheshire Disability. The home is a modern purpose built facility and includes a bungalow separate to the main building. All bedrooms are single and have en-suite bathrooms fitted with overhead hoists. A passenger lift is installed to access the two floors. On the day of our inspection the service was providing accommodation and nursing care to 20 people.

There was a registered manager in post although they were not present during 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.’

We identified four breaches of relevant legislation in respect of safeguarding service users from abuse, safe care and treatment and good governance. You can see what action we told the provider to take at the back of the full version of this report.

Overall the people and relatives we spoke with were positive about the care and support received at Hill House.

People told us that they felt safe from abuse and harassment and trusted the staff. However, we found that not all staff could demonstrate a clear understanding of the procedures they should follow if they witnessed or suspected that abuse had taken place. We were told about concerns by a member of staff and that they had not passed them on. As a result they had not been investigated or reported to the local authority and the Care Quality Commission (CQC) as required. This meant that people were not fully protected. We brought this to the attention of the deputy manager at the time of the inspection and it was then dealt with appropriately.

We saw that risk assessments had been recorded in people’s care records and that weight loss and pressure ulcer risks were regularly monitored. Accidents/incidents were not always recorded and we found that recording was not sufficiently robust.

Medicines were administered safely although we found that in some areas management systems needed to be improved. We saw that regular audits were taking place. There were two recent instances of missing medicines and we found that the process used for checking stocks needed to be reviewed.

At the time of the inspection we found that there were sufficient staff. Some people and staff told us that there were sufficient staff to meet their needs whilst others felt that this was not the case at night and weekend. We saw that staff received an induction and training was provided. Staff told us that they received the training and support they needed to carry out their roles effectively. Staff were also supported through supervisions although we saw that some were behind schedule. We found that safe recruitment systems were in place.

The environment was clean, spacious, fit for purpose and well decorated. Recent improvements had been made with the construction of an orangery extension and a sensory garden. Further works were planned to create an activity and physiotherapy centre within the grounds.

We were provided with two different versions of an emergency plan. We found that these lacked sufficient detail and guidance for staff in the event of a full evacuation. Following the inspection we received additional details which provided this information. A personal evacuation plan detailing each person’s individual needs was also in place.

We checked whether the service was working within the principles of the MCA, and whether any conditions to deprive a person of their liberty were being met. It was evident that the deputy manager had a clear understanding of the MCA and its application.

We saw that people’s nutritional needs were being met. People had choice and the food was of a high quality. People were supported to have sufficient to eat and drink and maintain a balanced diet. Staff were knowledgeable about people’s nutritional needs.

People received care that was personalised, effective and responsive to their needs. Care plans were detailed and contained sufficient information to enable staff to meet people’s needs. People spoken with told us that they were given choices about the way in which their care was delivered.

People looked happy, well cared for and were supported to maintain their independence. Staff were observed interacting in a kind, caring and attentive manner. An advocacy service provided by Leonard Cheshire Disability was available.

The home had two activities co-ordinators and there was a varied programme of activities taking place. Fully adapted transportation was available for outings. The service was supported by a well organised volunteer programme.

There was a complaints procedure available and people told us they knew how to complain should they need to. Regular meetings were held with the people living at Hill House and they were involved in decisions about their home.

We found that the home had systems in place to assess and monitor the quality of service, however actions identified were not always followed up and the systems had not been sufficiently robust to identify some of the issues raised during this inspection.

The three people who used the service we spoke with told us overall that they were happy with the care and support provided by the staff. People told us they felt able to raise any comments or complaints they may have with the manager and staff. We found that there were systems in place to appropriately manage people's comments or any complaints raised.

One person who used the service told us: "The staff are kind," they also told us that they they did not feel rushed when staff attended to their needs. Another person who used the service said: "Care homes are much as I had feared and expected, here though the staff are supportive" and: "I talk more to the staff and volunteers than I do the people who live here, because of their ability to chat, but I enjoy speaking with them all."

We reviewed two care plans and found that they contained sufficient detailed information about how staff could appropriately support peoples' needs, including their choices and preferences. We found that before people received any care or treatment they were asked for their consent and the manager and staff acted in accordance with their wishes.

We revisited the home 27 September 2012 to review whether staff recruitment records and documentation had improved. We did not ask people using the service about this outcome.

We saw in the four staff files reviewed that the necessary security and employment checks were undertaken before staff were employed to work with people who lived in Hill House.