Archived: Hill House Care Home

Hill House is a care home providing personal care to 18 older people at the time of the inspection. The service can support up to 40 people.

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

We have made a recommendation about the provider’s quality assurance systems and ensuring they identify incidents they must notify CQC about.

The provider had taken action to keep people safe and manage the risks they faced. Staff had a good understanding of the action they needed to take to keep people safe.

People were supported to take any medicines safely and staff sought advice from health and social care services when needed. People were happy with the care they received and felt safe at Hill House.

The provider had made changes in response to the COVID-19 pandemic and there were good infection prevention and control measures in place.

The registered manager worked well with people and their relatives to provide a person-centred service. They had developed good relationships with health and social care professionals.

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 25/04/2019)

Why we inspected

We received concerns in relation to medicines management and infection prevention and control measures. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were 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 Hill House Care Home on our website at www.cqc.org.uk.

Follow up

We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Hill House is a care home that was providing nursing and personal care personal to people. 28 people were living in the home at the time of the inspection.

People’s experience of using this service:

¿ The monitoring of medicine management needs further improvement. Guidance was not always available for staff to give people their medicines safely.

¿ Some people at times could display anxiety through verbal or physical behaviours. We found that the documentation around this to support staff was not always appropriate. There was no specific behaviour care plan or risk assessment in place.

¿ People told us they felt safe living at the home. Staff had the knowledge and confidence to identify safeguarding concerns and act on them to protect people.

¿ The meal experience for people was positive. Mealtimes were sociable and interactive and provided by attentive staff. People were informed of the choices and if they wanted an alternative this was provided.

¿ We saw that where a person lacked capacity an assessment had been completed. At times the assessments were generic and more information was needed around how information was given to a person to aid their decision making.

¿ People received care and support from staff who had got to know them well. Staff knew, understood and responded to each person’s needs in a caring and compassionate way.

¿ The provider had a system in place to monitor the quality of the service people received. However, some of the audits in place had not identified all of the issues that we found during this inspection.

¿ Services are required by law to send us statutory notifications about incidents and events that have occurred at the service and which may need further investigation. At this inspection we found the provider had failed to submit two notifiable events.

More information is in Detailed Findings below.

Rating at last inspection:

Requires Improvement (report published 21 June 2018).

Why we inspected:

This was a planned inspection based on the rating at the last inspection.

Follow up:

We have told the provider they must take action to improve the service. We have made two recommendations around medicines following this inspection. We will continue to monitor the service and complete a further inspection to assess whether the improvements have been made.

This inspection was a planned inspection to follow up on the concerns found at our last inspection in October 2017. At the inspection in October 2017 we found seven breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. A recommendation was also made in response to medicines management in the service. The service received an overall rating of 'Inadequate' and was placed into 'Special measures' by CQC. The purpose of special measures is to ensure that providers found to be providing inadequate care significantly improve. The concerns we found included ineffective assessment of risks to people, monitoring records not correctly completed and insufficient staff to respond to people’s needs.

Due to the number of concerns we wrote and met with the provider, to request an action plan to immediately address these shortfalls and keep people safe. The provider responded to this letter within the timeframe and has continued to send monthly improvement plans. The provider also placed a voluntary embargo on the service, which meant they would not increase the number of people they supported until they had made the necessary improvements.

At this inspection we found that improvements had been made and the service had met five of the previous breaches identified and part of another breach. The service remained in breach of two Regulations. The service is no longer rated as Inadequate and therefore will be taken out of ‘Special measures’. This service will continue to be monitored and re-inspected shortly, to ensure the improvements continue and are sustained.

The previous registered manager had left the service shortly after the last inspection. A new registered manager was now in post supported by a new management team. A consultant had also been working with the service since the last inspection to identify shortfalls and support the necessary improvements. 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. The registered manager, management team and owners were both present and available throughout our inspection.

Where there were risks to people these had been identified and a risk assessment put in place. However we saw that the information on some risk assessments was sometimes limited. A new format was in place for recording accidents and incidents; however these were not completed appropriately in order to be an effective investigation record.

People were supported by a sufficient number of staff who were currently supporting people in one building only. Staff felt that care was un-rushed and that they had time to spend talking with people.

At this inspection although we saw a few further improvements were needed, action had been taken to improve the management of medicines. People and relatives told us they were happy with the arrangements for staff managing medicines.

The service had not made the necessary improvements and remained in breach of the Regulation around consent. This is the second consecutive time the service has been in breach of this Regulation. The service did not always work within the principles of the Mental Capacity Act. Two people unable to consent to their care and treatment at Hill House did not have the appropriate legal documents in place.

The environment in the new building did not adequately support people’s orientation. There was a lack of signage to aid navigation to key areas such as the dining room or bathrooms. For people who had a diagnosis of dementia or visual impairment, consideration to their needs had not been considered in the design.

People were treated with kindness and compassion in their day-to-day care. We saw that staff responded to people in a respectful manner and took time to offer supportive care.

At this inspection we found the service had not made the necessary improvements to care plans and documentation and remained in breach of Regulation 17. This is the second consecutive time the service has been in breach of this Regulation.

People spoke positively about the opportunities they had and were supported to maintain and develop relationships that were important to them. Several people had close friendships in the home and staff supported people to spend time together by assisting them to sit together, or to go on outings together.

The service had a new registered manager in place who had been registered by CQC shortly before this inspection took place. The registered manager was realistic about the challenges they faced in making the necessary improvements and spoke of the things that had been implemented since they had taken up employment.

The registered manager had put in place systems to start monitoring the quality of the service people received. We observed some gaps on audits and not all of the concerns we identified had been picked up or action taken to make the necessary improvements. Due to some of the concerns raised at the last inspection the older building was currently closed to people whilst it was undergoing improvement work and redecoration.

We inspected Hill House Care Home on 18 and 19 October 2017, this inspection was unannounced. The service was previously inspected in October 2015 and received an overall rating of Good. In February 2017 the service increased the number of people they could support to 35 with the addition of a new contemporary building. The old building and the new are joined by a covered outside walkway. In addition the provider added the provision of nursing care to their registration. Work was underway to extend the new building which would provide a further 25 rooms. This will increase the service to 60 beds in total.

During this inspection we found seven breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. A recommendation was also made in response to medicines management in the service. You can see what action we told the provider to take at the back of the full version of the report.

The overall rating for this service is 'Inadequate'. This means that it has been placed into 'Special measures' by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

Services placed in special measures will be inspected again within six months. The service will be kept under review and if needed could be escalated to urgent enforcement action. Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

Due to the number of concerns we wrote to the provider requesting an action plan to immediately address these shortfalls and keep people safe. The provider responded to this letter within the timeframe and we are currently considering what action to take.

There was a registered manager in post when we inspected the service. 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.

Risks in the service had not been well managed. Risk assessments were not always updated to review safety measures. People did not always receive the care and support they needed to prevent risks in areas such as mobility and pressure area care. Fire records to make sure that people could be evacuated safely were not up to date and staff were not adequately trained to make sure they could respond effectively in the event of a fire.

Staffing levels in the home were not sufficient when taking into account the layout between two separate buildings and the number of floors. The registered manager did not calculate the staffing levels in accordance with people’s needs, but instead was told the numbers they could use by senior management. Staff had previously raised concerns around shortages, which had not been investigated.

Safe recruitment practices had not always been followed or the necessary checks completed to ensure new employees were safe to work with vulnerable adults.

Staff were not trained sufficiently in all areas to make sure they were effective in their roles. There was a lack of regular supervision to support staff to undertake their roles safely.

People’s choices were not always promoted or respected. This included decisions on where people preferred to spend their time and around meal choices.

We found concerns around staff understanding and recording of people’s mental capacity in the service. The service had accepted decisions made by relatives who did not have the legal authority to make decisions on behalf of people. Restrictions had been imposed on people without following the appropriate procedures.

Care records were not completed in sufficient detail to support staff to provide person-centred care. There was inconsistent recording which did not provide a clear picture of what people’s needs were. There was a lack of evidence to demonstrate that people had received a formal review of their care or been involved in a review process.

People’s complaints were not taken seriously or used as an opportunity to improve the service. Complaints had not been handled according to the provider’s policy.

The management and leadership within the home had not been effective and a breakdown of communication within the management team had impacted the delivery of care that people received.

There was insufficient quality monitoring in place. We were not confident the provider or management had oversight of the service. Accidents and incidents were not being monitored to reduce the risk of re-occurrence or share any learning points with the staff team.

We found that people were well looked after and people told us this. One person said "This is such a lovely place and the staff are wonderful". Another person invited us to see the vegetables they had grown in the vegetable patch and were rightly proud of. We observed that people moved around the home freely, that staff were attentive and respectful.

In response to the concerns raised, we asked the manager if they had received any complaints which related to these concerns. They told us they had not. We saw that the home had effective systems in place for responding to complaints and listening to informal issues or concerns. The manager showed us a book where staff, visitors and others could record things they wanted to be addressed.

We found that that the concerns raised were unsubstantiated as there were acceptable explanations and appropriate actions had been taken. Unfortunately, the provider had not had the opportunity to respond to the concerns directly. Had this been the case then the manager would had been able to provide clarification and evidence of the actions taken.

People were supported by staff to make their own decisions. Throughout our visit we observed that staff sought consent from people and supported them to make their own decisions. For example, in what they wanted to eat and drink or in taking part in the craft activity. We spoke with one person who told us, "If I can't decide something staff always come back later when I've made my mind up".

We saw that people were well cared for and were involved in their care planning. One person said, "I came in here for a break and it's been wonderful". A care worker explained that each person had a personal care plan which took into account their individual needs and preferences.

The chef said that people were asked what they would like to eat and made suggestions for the menu. They said that most people liked wholesome traditional food. All of the people we spoke with said how lovely the food was. We observed that lunch was a sociable affair and people really seemed to enjoy their food.

We found that appropriate checks were undertaken before staff began work and there were effective recruitment and selection processes in place. Information was available to people and their families on how to make a complaint.