Archived: Green Hill

Green Hill is a ‘care home’. 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.

Green Hill is a care home for up to 30 older people who live with dementia and require support and personal care. At the time of the inspection there were 16 people living in the home. The people who lived at Green Hill also lived with a degree of physical frailty, such as reduced mobility.

There was no registered manager in post. An acting manager has been in post since March 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. The acting manager has submitted their application to register and an interview date has been arranged.

In January 2016 the service was placed into administration and a consultancy agency was brought in to run the service to ensure the people who lived there were safe and cared for appropriately and in line with Regulations. Inspections undertaken since January 2016 have been overseen by the consultancy agency.

Since November 2014 we have inspected the service seven times and found continued breaches of Regulation. At a comprehensive inspection in July 2015 the overall rating for this service was Inadequate for the second time and the service was placed into special measures. At this time we took further enforcement action. Seven breaches of Regulation of the Health and Social Care Act 2008 (Regulated Activities) 2014 were identified. Due to concerns raised about the continued safety of people we undertook a responsive inspection in January 2016 to look at how safe the home was. We found improvement to people’s safety had not improved and therefore the rating remained inadequate. We inspected again on 25 and 26 May 2016 to see if improvements had been made. At that inspection we found considerable improvements to people’s safety had been made. However some areas required time to become fully embedded into everyday practice and further improvements made to fully meet the breaches. Our inspection in March 2017 found whilst improvements had been made in some areas there were two breaches of regulation because the premises were not clean and well maintained and the quality assurance systems had not identified the shortfalls we found.

We received new concerns in relation to people’s safety in November 2017. As a result we undertook a focused inspection on 17 November 2017 to look into those concerns and be assured of people’s safety. This report only covers our findings in relation to the key questions of whether the service is safe and well-led. You can read the report from our last comprehensive inspections, by selecting the 'all reports' link for Green Hill Care Home on our website at www.cqc.org.uk.

This inspection found people were placed at risk from unsafe premises because fire doors were not all working consistently and systems to support staff in managing an emergency evacuation were either incorrect or not available. The provider had also failed to inform CQC of on-going issues with fire safety which had the potential to impact on the safety of both staff and people at Green Hill Care Home. The lack of support care plans and risk assessments for people who had behaviours that challenge placed people and staff at risk from harm. Whilst medicines were ordered and stored safely there were improvements needed for the consistent recording of medicines and of the management of PRN medicines. Staffing deployment and staffing levels were insufficient to keep people safe.

We found there was a lack of consistent and strong leadership and provider oversight. We identified areas of record keeping that needed to improve to document more clearly the running of the home. For example, in relation to accident and incident records. There was an audit system in place however this had not identified all the shortfalls we found. Improvements were therefore needed in relation to auditing as a number of areas we identified had not been picked up as part of regular monitoring. This included auditing in relation to environmental and individual risk assessments and maintenance issues.

When staff were recruited, their employment history was checked and references obtained. Checks were also undertaken to ensure new staff were safe to work within the care sector. Staff were knowledgeable and trained in safeguarding adults and what action they should take if they suspected abuse was taking place. Staff had a good understanding of Equality, diversity and human rights.

People’s individual risks had been assessed and reviewed. Work had continued to ensure people’s needs were regularly reviewed with specialist advice sought as required, for example, dietician and GP referrals.

The overall rating for this registered provider 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.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

Green Hill is a care home for up to 30 older people who live with dementia and require support and personal care. At the time of the inspection there were 13 people living in the home. The people who lived at Green Hill also lived with a degree of physical frailty, such as reduced mobility.

There was no 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. In January 2016 the service was placed into administration and a consultancy agency was brought in to

run the service to ensure the people who lived there were safe and cared for appropriately and in line with Regulations. The consultancy agency have placed an acting manager in place until a permanent manager had been recruited.

Since November 2014 we have inspected the service six times and found continued breaches of Regulation. At a comprehensive inspection in July 2015 the overall rating for this service was Inadequate for the second time and the service was placed into special measures. At this time we took further enforcement action. Seven breaches of Regulation of the Health and Social Care Act 2008 (Regulated Activities) 2014 were identified. Following the inspection, we received an action plan which set out what actions were to be taken to achieve compliance by January 2016. Due to concerns raised about the continued safety of people we undertook a responsive inspection in January 2016 to look at how safe the home was. We found that improvement to people’s safety had not improved and therefore the rating remained inadequate. We inspected on 25 and 26 May 2016 to see if improvements had been made. At that inspection we found that considerable improvements to people’s safety had been made. However some areas required time to become fully embedded into everyday practice and further improvements made to fully meet the breaches. This included ensuring that peoples nutritional and hydration needs were appropriately met and the provision of person centred care. Documentation completed by staff needed further development to ensure best practice in all areas, specifically in respect of providing meaningful activities. The maintenance of the gardens and the interior of the building also needed attention to ensure people had the opportunity to use all areas safely. Following the inspection, we received an action plan which set out what actions were to be taken to achieve compliance by January 2017. We also received monthly updates of the progress made.

At this inspection whilst the staffing levels were sufficient to keep people safe, the lack of ancillary staff had not ensured that people were always treated with respect and dignity as the home was not clean and their clothing had not been treated with respect. It was also noticeable that there were not enough staff to engage with meaningful activities which would benefit and enhance people’s social and recreational needs.

There was an audit system in place however this had not identified all the shortfalls we found and when identified the shortfalls had not been actioned in a timely manner. The cleaning and maintenance of the premises was a particular area of concern.

People’s individual risks had been assessed and reviewed. Work had continued to ensure that people’s needs were regularly reviewed with specialist advice sought as required, for example, dietician and GP referrals. Medicine reviews were on-going and medicine practices ensured people received their medicines as prescribed.

The CQC is required by law to monitor the operation of Deprivation of Liberty Safeguards (DoLS). During the inspection, we saw that the management team had sought appropriate advice in respect of these changes in legislation and how they may affect the service. The management team knew how to make an application for consideration to deprive a person of their liberty and had submitted applications where they were deemed necessary.

Essential training had been undertaken. The training plan confirmed this. Staff said they felt supported and confirmed that they were having supervision. The manager acknowledged that there had been some staffing issues which had resulted in senior staff moving on and a new staff being employed so training and supervision was on-going as staff completed their induction. The manager said that they felt ‘improvements’ had been made and the staff were very committed to the home and the people who lived there.

Accidents and incident reporting had taken place. Records contained documented investigation and measures to ensure learning and future preventative measures. Staff had received safeguarding training on keeping vulnerable people safe from possible abuse and understood the process of reporting concerns. Staff had been checked to ensure they were suitable before starting work in the service.

We inspected Green Hill Care home 10 June 2016. This was an unannounced inspection

Green Hill is a care home for up to 30 older people who live with dementia and require support and personal care. At the time of the inspection there were 6 people living in the home. The people living at Green Hill also lived with a degree of physical frailty, such as reduced mobility.

There was no 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. In January 2016 the service was placed into administration and a consultancy agency was brought in to

run the service to ensure the people who lived there were safe and cared for. The consultancy agency had placed an acting manager in place until a suitable manager had been recruited. We were told a new manager was starting on the 13 June 2016.

Since November 2014 we have inspected the service four times and found continued breaches of Regulation. At a comprehensive inspection in July 2015 the overall rating for this service was Inadequate for the second time and the service was placed into special measures. At this time we took further enforcement action. Seven breaches of Regulation of the Health and Social Care Act 2008 (Regulated Activities) 2014 were identified. The inspection in July 2015 found significant risks to people due to the poor management of medicines and people not receiving appropriate person centred care. Where people’s health needs had changed considerably, care plans had not been updated. Staff did not have the most up to date information about people’s health. This meant there was a risk that people’s health could deteriorate and go unnoticed. Risk assessments did not reflect people’s changing needs in respect of wounds and pressure damage. Accidents and incidents had not been recorded appropriately and steps had not been taken by the staff to minimise the risk of similar events happening in the future. Risks associated with the cleanliness of the environment and equipment had been not been identified and managed effectively. People had not been protected against unsafe treatment by the quality assurance systems. We also found that training had not been delivered where identified as needed and administrative processes to support training, staff supervision and appraisal were inaccurate and incomplete.

Following the inspection, we received an action plan which set out what actions were to be taken to achieve compliance by January 2016.

Due to concerns raised about the continued safety of people we undertook a responsive inspection in January 2016 to look at how safe the home was. We found that improvement to people’s safety had not improved and therefore the rating remained inadequate.

During our inspection on 25 and 26 May 2016, we looked to see if improvements had been made. At this inspection we found that considerable improvements to people’s safety had been made. However some areas required time to become fully embedded into everyday practice and further improvements made to fully meet the breaches. This included ensuring that peoples nutritional and hydration needs were appropriately met and the provision of person centred care. Documentation completed by staff needed further development to ensure best practice in all areas, specifically in respect of providing meaningful activities. The maintenance of the gardens and the interior of the building also needed attention to ensure people had the opportunity to use all areas safely.

At this inspection we found that the management of nutrition and hydration needed to improve further to ensure people’s nutritional and hydration needs were consistently met and the meal times were an enjoyable experience.

The staffing levels were sufficient for the six people who lived in the home to keep them safe. However it was noticeable that there were not enough staff to engage with meaningful activities which would benefit and enhance people’s social and recreational needs.. We were aware that the in reach team (the NHS In Reach Team has been set up to work alongside care homes in developing dementia care.) commence a 12 week programme on the 13 June to develop person centred care workshops for people living with dementia. This had been planned previously but due to a complete change of staff this was delayed until all staff had completed their induction to care at Green Hill Care Home.

People’s individual risks had been assessed and reviewed. Significant work had been taken to ensure that people’s needs had been re-assessed with specialist advice sought as required. For example, dietician and GP referrals. Medicine reviews were on-going and medicine practices ensured people received their medicines as prescribed.

Peoples care documentation had been rewritten by the acting manager in February 2016. Overall the care plans were adequate. However it was often unclear when the care plan had been implemented. Although reviewed in May 2016, the review process failed to tell staff whether the care plan remained effective; what changed, what was working well and the residents view on how they found their care plan. Mental capacity assessments were not consistently decision specific and were often generic. Staff told us they understood the principles of consent and therefore respected people’s right to refuse consent. However in practice staff were unsure of how to use their training when people were resistant to personal care. The care planning process gave consideration to Deprivation of Liberty Safeguards (DoLS) and how care could be provided in a least restrictive manner but some urgent DoLS had expired and no evidence of resubmission. This lacked management oversight.

Essential training had been undertaken. The training plan confirmed this. Staff said they felt supported and confirmed that they were having supervision. There were gaps identified in training specifically around dementia training and the management of behaviours that may challenge. The manager acknowledged that there had been some staffing issues which had resulted in senior staff moving on and a new staff being employed so training and supervision was on-going as staff completed their induction. The manager said that they felt it was now coming together and there was a core strong caring team of staff.

Accidents and incident reporting had taken place and were recorded. Records contained documented investigation and measures to ensure learning and preventative measures. Staff had training on keeping people safe and understood the process of reporting concerns. Staff had been checked to ensure they were suitable before starting work in the service.

Staff had attended staff meetings to enable them to raise concerns and discuss issues collectively.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

We carried out unannounced inspections of this service in November and December 2014, March 2015, and July 2015. Due to continued breaches of Regulation and unmet warning notices, we served a notice to close the service in August 2015. The service was placed in to special measures and the local authorities placed an embargo on admissions to Green Hill. We received new concerns in relation to people’s safety in December 2015. As a result we undertook a focused inspection on 14 January 2016 to look into those concerns and be assured of people’s safety. This report only covers our findings in relation to the key question of whether the service is safe. You can read the report from our last comprehensive inspections, by selecting the 'all reports' link for Green Hill Care Home on our website at www.cqc.org.uk

Although people told us that they felt safe in this home, we found areas of care delivery that placed people at risk. There had been a number of people with unexplained bruising and injuries that had not been reported to the local authority safeguarding team for investigation. The injuries had not been reviewed by the manager and there was no plan in place to promote people’s safety. The records pertaining to these injuries were not photographed as a means of monitoring, or analysed to see if there was an identified trend. Additional safety measures had not been put in place. For example, one staff member said that she thought some injuries for one person looked like finger marks. We asked if this had been taken forward to the registered manager and was told it had been mentioned. We found no incident record that confirmed this or a referral to safeguarding.

Risk assessments for people were in place, however not all were reflective of people’s current needs in respect of nutrition, continence and mobility. We saw people were at risk from trips and falls due to poorly fitting foot wear and lack of additional aids to support people who were unsteady, such as transfer belts. We saw that equipment such as a hoist and stand-aid were used to move people without a moving and handling assessment being undertaken.

There were people who needed nursing care to meet their increased needs. These people had not been referred to the local authority for assessment and review until it was identified during our inspection.

Not all equipment in use for people, such as beds and moving and handling equipment were in good working order. This placed people and staff at risk from injury.

Whilst staffing levels were stable at three care staff during the day and two at night, the deployment of staff did not ensure that peoples’ safety, health and social needs were met consistently. At times people were left unsupervised in the dining area or the communal space. People told us that they were bored. We saw that people were not offered the opportunity to visit the bathroom.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.

We examined four care plans and saw evidence that delivery of care was person centred. Care plans and activities were designed and carried out to give people new experiences and independence while keeping them safe.

We found good management processes in place in relation to obtaining, storing, administering and disposing of medicines. Staff administering medication were appropriately trained and gave support to people where required.

Records we examined showed that there were appropriate checks made to ensure the home recruited suitable staff. Staff we spoke with felt well supported and enjoyed working at the home.

We saw that the home was decorated to a good standard. It was homely and designed or adapted as necessary to ensure it was a safe environment for the people living there.

We examined systems and records kept by the home and saw that there were good levels of quality assurance monitoring to maintain standards. These included analysis of satisfaction surveys, feedback from staff meetings and regular reviews of care plans, procedures and practices at the home.

We saw that people were treated with dignity and respect and that they were supported to remain their independence.

People were offered a choice of food which was nutritious and varied. We observed staff interacting positively with the people who used the service.

We saw that the provider has effective quality assurance systems in place to identify, assess and manage risks to the health, safety and welfare of people using the service and others.