We carried out a review of the data available to us about Hillcroft House on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Hillcroft House, you can give feedback on this service.
People’s experience of using this service and what we found
We found concerns at our last inspection and rated the home requires improvement in two key questions and overall. We also found a breach of the Health and Social Act 2008 (Regulated Activities) Regulations 2014. At this inspection we found that the provider was no longer in breach and had made the necessary improvements.
People told us they felt safe and we observed they were at ease in the company of the staff that cared for them. People were protected from the risk of potential harm; safeguarding policies and processes were in place and staff had received appropriate training.
Risks to people were regularly assessed with measures in place to mitigate them. This included timely referrals to healthcare services. Safe management of medicines was in place.
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.
There were sufficient safely recruited staff on shift to meet people’s needs. The provider was actively recruiting additional staff but in the meantime was using preferred agency staff, where required, to maintain safe staffing levels. We have made a recommendation about staffing.
Despite recent changes in the leadership in the home, staff were clear on their roles and responsibilities. Morale and the culture in the home was good, staff said the interim management arrangements the provider had taken had settled the home and staff felt supported in their role.
Governance systems supported the provider and management team to identify shortfalls in the home and address them. Processes were in place to learn lessons when things had gone wrong with actions taken to reduce future incidents happening.
Overall, the home was clean and hygienic with good infection control procedures carried out. Staff wore appropriate personal protective equipment (PPE). We noted that some parts of the home were in need of attention and this was addressed during our inspection. The management team shared the provider’s programme of scheduled works which included improving the décor and layout of the home to benefit the people living there.
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 28 April 2020) and there was a breach of regulation. 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 the regulation.
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.
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 and Well-led which contain those requirements.
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 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 Hillcroft House 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.
Hillcroft House is a residential care home for up to 43 people living with dementia. On the day of our visit 40 people were living at the service. This care home consists of an older building and newer extension. It is within walking distance to Stowmarket town centre.
People’s experience of using this service and what we found
People told us they were happy living at the home however, we identified some shortfalls that had not been picked up through the providers governance systems. Nutritional risks to people’s welfare had not been consistently assessed and appropriate action taken to mitigate the risks. Medicines were not always managed safely.
There was a new manager who had been in post three weeks at the time of our inspection visit and had already begun to make improvements such as increasing the staffing numbers.
Staff knew how to safeguard people from the risk of harm and abuse. Staff were recruited safely, and they received appropriate training and support to equip them with the necessary skills.
We received positive feedback from people and their relatives about the caring nature of staff. People were treated with kindness and compassion.
People’s meal time experience would benefit from further review and co-ordination. We have made a recommendation about this.
The home was clean and well maintained. The design and décor of the building took account of 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.
People had their needs assessed and care plans were developed. These described people's needs and gave staff guidance in how to meet them in ways they preferred. The provider had a system to manage complaints. People and their relatives were aware of how to complain and told us they felt confident any concerns they may have would be listened to and addressed. People's end of life wishes were sought.
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 22 June 2017).
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Hillcroft House on our website at www.cqc.org.uk.
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 the last inspection on 14 October 2015, the service was rated Good. At this inspection we found the service remained Good.
We found a care home that was well run for the benefit of the people who lived there. People spoke highly of the service offered and felt appropriately cared for. People experienced good care with on-going monitoring of health needs and prompt access to health services. Visiting health professionals told us that the service was caring and met the needs of people who lived here. There was varied, needs led social stimulation and people liked the variety and quality of food on offer. Mealtimes were a pleasant experience for everyone.
Staff told us that they had the training and support to carry out their roles effectively and confidently. Staff spoke highly of the management who they said were approachable and made positive changes when needed. Staff were happy and positive. This exuded from some who sang and danced through their working day whilst positively supporting people. This light-heartedness was felt by the people being supported and prompted them to smile and join in. People looked happy and there was a degree of calm and people had purpose to their day.
There were sufficient numbers of staff to meet people needs. People were safeguarded from the potential of harm and their freedoms protected. Staff were provided with training in Safeguarding Adults from abuse, Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). The manager knew how to make a referral if required.
Medicines were safely managed. The manager had oversight and had thorough quality assurance processes in place that were fed up and monitored by the wider organisation. The manager was supported appropriately by the provider and spoke positively about developments and resources being available to them.
Further information is in the detailed findings below.
We completed an unannounced inspection of Hillcroft House on 14 October 2015. Hillcroft House Residential Home is registered to provide accommodation for people who require personal care. The service provides places for up to 43 people. At the time of our visit 40 people were resident. This care home is part converted and part purpose built.
There was a registered manager in place and they were present on the day of our 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 found a care home that was well run for the benefit of the people who lived there. Everyone spoke highly of the service offered and felt appropriately cared for. People told us that their needs were assessed, they were involved with their care and were consulted about changes. People experienced good care with on going monitoring of health needs and prompt access to health services. There was varied, needs led social stimulation and people liked the variety and quality of food on offer.
The service did not ensure that there were sufficient quantities of medicines to ensure the safety of service users and meet their needs. Risks associated with medicine management were not mitigated and the service did not maintain securely an accurate, complete and contemporaneous record in respect of each person’s medicines.
Staff had the skill to support people and were well trained. There was a good team approach and collaborative working. Staff felt supported by management and liked where they worked.
Management was open, inclusive and regularly listened to people who used the service. There were systems in place to monitor and respond to events that occurred and feedback from people was used to develop the service further.
You can see what action we told the provider to take at the back of the full version of the report.
One person who used the service told us, 'I enjoy going out on the bus and today we are going to feed the ducks.' Another person said, 'The food is fresh and very cooked.' We saw the menus provided a variety of choice and meals were served in the dining rooms of the service or in the persons room depending upon their choice. We saw there was a variety of activities arranged for every weekday.
We inspected the staffing rota and saw there were sufficient staffing levels for the service across the twenty-four hours of the day. The service was able to cover vacant shifts when they occurred from within their own staffing establishment and hence the staff knew the people that used the service. We also saw the service had a complaints system in place and when complaints were made which was rare they were resolved quickly and to the satisfaction of all involved. The service was working with other providers of care in order to support the service meet the individual care.
We saw that activities were well planned and were designed around people's interests and preferences. People told us about the social activities they had taken part in such as a weekly 'club' meeting, or making decorations.
Staff were recruited appropriately and received relevant training to meet people's needs. The service had effective quality assurance systems in place. This meant that they were able to monitor the effectiveness of the service and make improvements as necessary.
There has been no further information provided since our last review of the service. We did not seek comments from people during this review.