Hilgay Care Home

Hilgay Care Home is a residential care home providing accommodation and personal care in one adapted building for up to 35 older people living with frailty, dementia and other health related conditions. At the time of the inspection there were 17 people living at the home.

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

People told us they were happy with the service they were receiving and described staff as being kind and caring. One person commented, “I am very happy here, the staff are all pleasant and easy to get on with.”

Improvements found at the last inspection had been sustained and people were receiving safe and effective care.

Risks to people were assessed and managed. There were clear care plans in place to guide staff in how to provide care safely. People were receiving their medicines safely and records were accurate. There were effective systems to monitor incidents and accidents and to make improvements when things went wrong. Staffing levels were safe and recent recruitment had been successful.

Staff had received the training and support they needed to care for people’s needs. Staff were proactive in ensuring people could access the health care services they needed. People were being supported to have enough to eat and drink and spoke highly of the food available. One person told us, “There is always a good choice, lots of options to choose from.”

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 had developed positive relationships with people. One person told us, “They (staff) are all lovely.” Another described two staff members as, “The dream team.” Staff were respectful of people and their wishes. People were supported to be as independent as possible and were supported to express their views. Care plans reflected people’s voice and supported staff to understand their needs and preferences.

Care was delivered in a personalised way that was responsive to people’s needs and wishes. People described being offered choices and feeling in control of their care. People were involved in developments at the home, one person described working with staff to create an activity room where people could go to follow their interests.

People said they felt comfortable to raise any concerns and were confident complaints would be listened to and addressed by the registered manager. People and staff expressed confidence in the leadership and skills of the registered manager. Effective systems were embedded within practice to monitor the quality of the service and to drive improvements.

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 13 October 2020)

Why we inspected

This was a planned inspection based on the previous rating.

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.

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.

Hilgay Care Home is a residential care home providing accommodation and personal care in one adapted building for up to 35 older people living with frailty, dementia and other health related conditions. At the time of the inspection there were 14 people living at the home.

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

At the time of this focused inspection, due to the risk of COVID-19 some people were being supported in their rooms as part of a two-week isolation period when they were admitted to the home.

Significant improvements had been made since the last inspection. People and their relatives talked of a ‘turnaround’ in the way the home was managed and how pleased they were with changes that had been implemented. One person said, “We have a new activities lady now and I enjoy doing armchair exercises. I used to just come downstairs for meals, but I come down more now because there is more to do. I used to get sad and lonely, but I’m feeling better now”. Two relatives felt that any concerns they had would be listened to and addressed. One relative added, “I keep in contact over the phone and the manager keeps me up to date. The home has a Facebook page and I can see photos”.

People spoke confidently about the registered manager and were positive in their feedback. Staff had an enthusiastic and caring approach to their work, which was observed at inspection.

People’s risks were identified, assessed and managed safely. If accidents or incidents occurred, these were reviewed and analysed; lessons were learned to prevent a reoccurrence. People received their medicines as prescribed. Infection prevention and control procedures were effective and applied rigorously. New staff were recruited safely, and checks were made on their suitability to work in a care setting. Staffing levels were sufficient to meet people’s needs.

Auditing systems continued to be implemented well and were effective in monitoring and measuring the care delivered and the home overall. The registered manager adopted a pro-active approach, demonstrated a keen and passionate understanding for building and sustaining the improvements already implemented, and involving staff in the management of the home.

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, (report published 17 March 2020). Conditions were placed on the provider’s registration between March and June 2020. This required the provider to advise CQC on new admissions, and for the services of an external consultant to advise the registered manager about setting up auditing systems. At this inspection we found improvements had been made, and the conditions to registration have now been removed.

Why we inspected

We undertook this focused inspection to check whether improvements made at the last inspection continued to be sustained and be embedded into practice. This report only covers our findings in relation to the Key Questions Safe and Well-Led.

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.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has remained as Requires Improvement. 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 Hilgay Care Home 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.

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

Improvements had been made across all areas of practice at the home. Since the last inspection the number of people living at the home had reduced and the occupancy level was now 23% of the home’s capacity. The level of risks had reduced and only one person had significant complex needs. Staffing levels had improved and this meant that people were experiencing a better quality of life. Since the last comprehensive inspection there had been regular involvement with health and social care professionals to address safety concerns at the home. Improvements to the systems and processes for management of the home had happened since November 2019 and were not yet all fully embedded and sustained over time. There remained some areas of practice that needed further improvement.

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. Some staff did not demonstrate a clear understanding of their responsibilities regarding MCA and DoLS. We did not identify impact for people at this inspection but there was a risk that people’s human rights might not be protected.

There were improvements in communication between staff and managers. Some further consideration was needed to ensure that systems for communication did not compromise people’s confidentiality. The culture at the home had improved and staff were positive about the changes that had been made. There were concerns about how staff were supported with the provider’s whistleblowing policy.

Risks to people were assessed and managed. There were enough staff to care for people safely and people told us they felt safe. Staff understood their responsibilities for safeguarding people and incidents were reported appropriately. Medicines were managed safely.

Assessments and care plans were clear and had been reviewed and updated to reflect the care that people were receiving. Staff had received the training they needed to care for people safely and told us that they felt well supported by the new management team. People were supported to access health care services when they needed to. People had enough to eat and drink and staff were aware of people’s nutritional and hydration needs.

People spoke highly of the staff and the care they received. One person said, “They are all very kind.” Staff knew people well and supported them to express their views. People told us they had been involved in developing their care plans.

Complaints were recorded and concerns were addressed. People were receiving care in a personalised way and staff were responsive to changes in people’s needs.

New systems for assuring quality and driving improvements had been introduced and the manager and quality director were working to an improvement plan. This had led to positive changes in safety and people’s quality of life. People and staff told us they had noticed the changes and spoke positively about the new manager.

The level of occupancy at the home is low and risks to people have reduced. Many positive changes have been introduced by the new management team since November 2019. More time is needed to assess how these changes are embedded and sustained in practice.

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 Inadequate (published July 2019) and there were continued breaches of regulations. The last comprehensive inspection on 8 and 10January 2019 rated the service as inadequate and we issued warning notices telling the provider they had to make improvements within a specified time frame. A focussed inspection took place in April 2019 to check if the provider had made the necessary improvements. The service had deteriorated further so we took appropriate action to address the level of serious concerns. A further focussed inspection in July 2019 was undertaken in response to further information of concern received. This confirmed that there remained continued breaches of regulations and we continued with action to address the level of serious concerns.

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 there were no breaches of the regulations. This service has been in Special Measures since January 2019. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This was a planned inspection based on the previous rating. This inspection was carried out to follow up on action we told the provider to take at the last inspection. 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.

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.

Hilgay is a residential care home providing accommodation and personal care for up to 35 older adults living with frailty, dementia and other health related conditions. At the time of the inspection there were 11 people living at the home.

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

The service was not well-led, the provider lacked oversight of the care people received. Required improvements had not been made which affected the safety and experiences of people living at the home.

Systems to monitor the quality and safety of the provider’s continuous improvement were not effective. The systems did not proactively monitor areas where the care delivered was not safe or meeting standards. This had led to repeated cases of people being exposed to risk.

There had been a recent instability in the management arrangements at the home, leading to significant shortfalls in the leadership of the service which staff told us, had resulted in feeling “low in morale,” “stressed,” and feeling, “unsafe.” A new manager had been in post since 20 June 2019 during which time they had started to develop positive relationships with people, relatives and staff.

People remained at risk as identified risks to them had not been safely reduced. Risk management processes were poor and specific risks to people’s health such as skin damage had not been effectively managed, and people had experienced harm.

Medicines were not managed in line with regulatory requirements and best practice guidelines.

Staffing levels were not always aligned to people's assessed needs. People and staff said they felt there was not sufficient staffing to meet people's needs.

People were protected by staff who were trained in safeguarding. Staff described to us scenarios where they had made alerts to the local authority when they had concerns about people's welfare.

There was a robust recruitment programme which meant all new staff were checked to ensure they were suitable to work with people.

Our observations during the inspection, were of positive and warm interactions between staff and people who lived in the home. Staff treated people with kindness, dignity and respect and spent time getting to know them and their specific needs and wishes. One person said, “The staff are very good and very hard working, very helpful.”

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 inadequate (published 3 July 2019) and there were multiple breaches 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 not enough improvement had been made/sustained and the provider was still in breach of regulations.

Why we inspected

We received concerns in relation to the management of unsafe medicines, staffing levels, staff competency and infection control. As a result, we undertook a focused inspection to review the Key Questions of Safe and Well-led only.

We have found evidence that the provider needed to make improvement. Please see the Safe and Well Led sections of this full report.

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 remained inadequate. 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 Hilgay care home on our website at www.cqc.org.uk.

Enforcement

We have identified continued breaches in relation to the arrangements for keeping people from harm to self or others, the management of medicines, deployment of staff and good governance.

Under Section 28(3) of the Health and Social Care Act 2008, we served a notice of decision to cancel the registration registration as a provider in respect of the regulated activity; accommodation for persons who require nursing or personal care.

People’s experience of using this service:

¿ There had been significant and continued failings by the provider to improve the quality of care people received following the last inspection. Concerns identified at the last inspection had not been addressed or improved and breaches of regulations remained. ¿ The service was not well-led, and the provider and management team lacked oversight of the care people received. There had been significant shortfalls in the leadership of the service which had resulted in people experiencing poor quality care.

¿ People were not protected from the risk of avoidable harm. People were not protected from the risk of abuse. Several incidents of unexplained bruising had not been identified as potential safeguarding concerns by staff, senior staff or the provider.

¿ People remained at significant risk as identified risks to them had not been safely reduced. Risk management processes were poor and specific risks to people’s health such as choking, and skin damage had not been effectively managed, and people had experienced harm.

¿ Staff told us they did not feel supported in their roles and that there was a poor culture within the home between them and the management team. One member of staff told us, “No leadership, we need that and we’re not getting it. We have no one to ask (for support). (Current consultant) is a help, no one else knows anything all locked away in the office.”

¿ Quality assurance processes were ineffective at identifying issues and improvements were not made to the quality of care people received. Concerns identified at the last inspection had not been addressed by the provider.

¿ Staff did not have access to training to develop their knowledge and to support people safely. The management team were not always assured of staff competency.

¿ Staff and the management team did not always work effectively with other professionals to ensure people’s needs were met in a timely way, specifically relating to raising potential safeguarding concerns. ¿ People were not always protected from infection control risks. Some people did not have consistent access to hot water in their rooms. People told us that they were unable to wash their hands effectively after going to the toilet during the day because of this. This increased the risk of people experiencing potential ill health.

¿ People were supported to have maximum control over their lives and staff supported them in the least restrictive way possible.

¿ Some people were happy with the food provided and had access to regular fluids and snacks.

Rating at last inspection:

Inadequate (The last report was published on 30 March 2019). The rating at this inspection remained Inadequate.

Why we inspected:

This was an unannounced focussed inspection. This inspection looked at the key questions of Safe, Effective and Well Led and to check if the provider had reached compliance with enforcement action issued following the last inspection.

Enforcement:

We found four continued breaches of regulation. The overall rating for this home remains 'Inadequate' and the home is therefore remaining in special measures. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. 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. 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 in inspections and appeals is added to the report after any appeals have been concluded.

Follow up:

The overall rating for this service remains Inadequate and the service continues to be in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the providers registration, we will re-inspect within six months to check for significant improvements.

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

The service had a registered manager. 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 provider of Hilgay Care Home was also the registered manager and they were present throughout the first day of the inspection and part of the second day.

At the last inspection on 23 April 2018 we rated the home as Requires Improvement. This was the third occasion that the home had been rated Requires Improvement. Following the last inspection, we met with the provider to confirm what they would do, and by when, to improve the key questions of is the service safe and well led to at least Good. The provider submitted an action plan which detailed how they planned to make the required improvements.

We received information from the local authority about a number of safeguarding concerns at the home. This indicated potential issues with the management of risks of people falling. We examined these risks as part of this inspection.

At this inspection the registered manager had not maintained improvements seen at the last inspection and standards at the service had deteriorated. We identified serious concerns which put people’s health and well-being at risk.

There were not enough staff to care for people safely. Staff did not all have the training that they needed to be effective in their roles. Some staff had been deployed to work with people during their induction period without having received the training they needed to assist people to move safely.

Risks to some people were not being effectively managed. When people had falls, systems for reviewing their needs were not robust and adjustments were not always made to mitigate risks. Some people needed support to move using equipment. Assessments and care plans did not provide clear guidance for staff in how to support people safely. Some assessments were completed by staff who did not have the necessary training and experience. We raised a safeguarding alert with the local authority following the inspection.

Incidents and accidents were recorded. The registered manager had oversight of these records but had failed to identify patterns and trends. They had not taken all reasonable steps to prevent further occurrences or to mitigate risks to people.

Systems and processes for management at the home were not effective and there was an over reliance on the registered manager. There were not sufficient trained staff willing to administer medicines to people. This had resulted in the registered manager working an unsustainable number of hours over an extended period. Suitable contingency plans were not in place which put people at risk of not receiving their prescribed medicines when the registered manager was unexpectedly away from the service. A safeguarding alert was raised by the deputy manager during the inspection.

The system for managing complaints showed that two complaints had been received since the last inspection. However, people, their relatives and staff told us about a number of other complaints that had been raised but were not recorded. People told us they had no confidence that their concerns were taken seriously and addressed by the registered manager.

There was a lack of strategic management and oversight which meant that there had been a failure to make improvements following the last inspection. The registered manager had failed to ensure that incidents were reviewed and considered in line with the provider’s safeguarding policy.

Records of staff rotas were not always accurate and this meant we could not have confidence that staffing levels were being maintained as described by the registered manager.

There was a widespread lack of confidence in the registered manager. This was expressed by staff, people, their relatives and health and social care professionals. One staff member said, “The manager doesn’t listen, we have all said the staffing levels are too low and nothing changes.”

People and their relatives told us that staff were usually kind and caring. A person told us that some staff were “A bit snappy.” One person told us they thought this was because staff were under pressure.

People were supported to have enough to eat and drink but risks associated with choking were not always identified and acted upon. We asked the deputy manager to assess one person who we observed to be coughing at meal times during both days of the inspection.

Staff checked with people before providing care. Care plans showed that decisions made in people’s best interests were recorded and relatives had been included in the process. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

We found five breaches of the Regulations. The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

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.

The service had a registered manager. 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 provider of Hilgay Care Home was also the registered manager and they were present throughout the inspection.

At the last inspection on 26 September 2017 we found a continued breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, because there were not sufficient numbers of suitable staff employed. We also identified other areas of practice that needed to improve. We issued a warning notice requiring the provider to become compliant with the legal requirements by 31 January 2018. The provider sent us an action plan on 21 February 2018 to tell us what they had done to meet the legal requirements in relation to staffing. At this inspection, on 23 April 2018, we found that the improvements set out in the warning notice had been made and the previous breach had been addressed. However, we identified further areas of practice that required improvement.

Policies and procedures were in place to guide staff, however some policies were not being followed. The registered manager used a number of management tools to monitor standards and quality and to provide oversight. However, these systems were not always effective in identifying shortfalls in practice. Governance is an area of practice that requires improvement.

Staff understood how to recognise abuse and how to report concerns. However, processes to safeguard people from harm and abuse were not consistently followed in line with local safeguarding arrangements. This is an area of practice that needs to improve to ensure that people are consistently protected.

People told us they felt safe living at Hilgay, one person said, “There are always staff around to help us.” Risks to people were assessed and managed and there were plans in place to guide staff in how to support people safely. People were receiving their medicines from staff who were trained to administer medicines safely. Incidents and accidents were recorded and monitored so that lessons were learned when things went wrong. There were systems in place to ensure that people were protected by the prevention and control of infection.

Staff were receiving training and support relevant to their roles. Communication between staff was effective. One staff member said, “We have very good team work here.” People’s consent to care and treatment was sought and staff understood the principles of the Mental Capacity Act 2005.

People’s needs were assessed, monitored and managed. People were supported to have enough to eat and drink and staff supported them to access health care services when they needed to. One person told us, “They look after me very well.”

People and their relatives told us that they were happy with the care provided. One relative said, “The staff are so caring, kind, friendly and attentive. It’s a home from home.” People were encouraged to express their views and to be involved in planning their care. Relatives also described being involved and being kept informed of any changes. People’s privacy and dignity was supported. Staff encouraged people to be as independent as possible.

At the last inspection on 26 September 2017 we found that people’s social needs were not always being met because there was a lack of social stimulation. At this inspection improvements had continued to be made and people reported greater satisfaction with the range of activities available.

Care records were personalised and included details of people’s diverse needs. One person told us, “Everyone is helped in different ways.” Another person said, “The know me well and know my likes and dislikes.” Care records included plans for end of life care.

People and relatives felt able to raise any complaints and records showed that action was taken to address people’s concerns. Systems were in place to monitor quality and seek feedback from people and their relatives. Audits were used to monitor quality and action plans were developed to drive improvements.

Staff had made links with organisations from the local community which benefitted people living at Hilgay. Staff worked in partnership with other agencies and sought appropriate advice from health and social care professionals. The registered manager had a clear vision for the home which was communicated and understood by the staff, people and their relatives.

We identified one breach of the regulations. You can see what action we told the provider to take at the back of the full version of the report.

The registered manager had left in June 2017 and at the time of the inspection there was no registered manager. 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 provider was in the process of applying to become the registered manager.

At the last inspection on 19 and 20 July 2016 we found breaches of four regulations relating to inadequate levels of staffing, lack of support at meal times, lack of person centred care and poor management oversight. The provider sent us an action plan on 4 October 2016 explaining what they would do to ensure that they were meeting the regulations by the end of November 2016. At this inspection on 26 September 2017 we found that some improvements had been made but there continued to be a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, because there were not sufficient numbers of suitable staff employed. We also identified other areas of practice that needed to improve.

People, their relatives and staff all told us that there were not enough staff on duty. People were having to wait for their care needs to be met. One person said, “I always have to wait a long time for my call bell to be answered.” During the inspection we observed that people’s call bells were not always answered promptly and one person waited for 30 minutes. One person said, “Sometimes I wait so long for staff to come I wet myself.” A relation told us, “They (staff) try their best, but they are always short staffed.” Staff members we spoke with were all clear that there were not enough staff on duty. One staff member said, “The care gets done but people have to wait for it.” The provider was using high numbers of agency staff to cover for vacant posts over a sustained period of time. Staff told us that agency staff were not always available. Records showed that staff numbers had not remained consistent with the provider’s dependency tool which identified how many staff were needed to care for people’s needs safely. This meant that the provider had not fulfilled their plan to improve staffing levels following the previous inspection in July 2016 and it remained that there were not always enough staff on duty to care for people. Following this inspection, we received further information about staff working at night who were not trained to administer medicines. This showed that the provider had not ensured that the skill mix of staff was always suitable to meet the needs of people. This was a continued breach of the regulations.

The provider had put an action plan in place following the last inspection on 19 and 20 July 2016 to address the breaches that were identified. Whilst they had followed their plan in most respects and met the previous breaches, there had been a failure in management oversight to ensure that improvements needed were effectively identified and sustained. This was identified as an area of practice that needed to improve.

People’s social needs were not always being met. The number of organised group activities had improved since the last inspection and people told us that they enjoyed the organised activities provided. However at other times people did not have enough to do. One person said, “There is nothing for me to do here, what can I do?” Consideration was not always given to people’s gender, their individual needs and preferences. People told us they were bored and our observations confirmed that people had little access to activities or occupations that were stimulating and relevant. This was identified as an area of practice that continued to need improvement.

Risks to people were being identified, monitored and managed. People told us they felt safe living at the home. One person said, “Staff help me when I get anxious.” Risk assessments and care plans guided staff on how to provide care to people safely. People told us they received their prescribed medicines when they needed them and we observed that staff were managing the administration of medicines safely.

Staff understood their responsibilities to safeguard people and knew how to report any concerns. There were robust recruitment procedures in place to ensure that staff were suitable for their roles.

People had confidence in the skills of the staff. One person said, “I can’t fault the staff they are all good.” A visitor said, “The staff are very clued –up, they definitely know how to care for people.” Staff told us they were supported and had opportunities for training and records confirmed this. Staff had received training in the Mental Capacity Act 2005. They understood their responsibilities regarding gaining consent from people. One staff member said, “We need to get people’s agreement for things, if they don’t consent we have to accept their decision.”

People told us they enjoyed the food at Hilgay Care Home and they were receiving the support they needed to have enough to eat and drink. The chef had good knowledge of people, their needs and preferences. One person said, “We have lovely food here, yes very good.” People told us they were supported to access health care service when they needed them. A visiting health care professional told us that staff made appropriate referrals in a timely way.

Staff had developed positive relationships with people and knew them well. One person said, “They are all caring and kind. Not a bad one amongst them, including the agency girls.” Staff were kind and caring in their approach and respected people’s dignity. People were supported to make decisions about their care. One person said, “They are always asking me for my views. I tell them I don’t mind.” A relative said, “We are here today to discuss how things are going.”

Care plans were well personalised with details that supported staff to provide care in a person centred way. We observed that staff were familiar with people’s chosen routines and noticed changes in their needs. Care plans were reviewed and updated regularly and gave an accurate description of the care provided.

People told us they knew how to complain and would speak to the manager or a member of staff if they had any concerns. The provider had a complaints system in place and this was visible in the home.

There were a number of management tools used to monitor standards and quality of the service. The management structure was clear and staff understood their roles and responsibilities. Staff and people said that they had a visible presence in the home, one person said, “The owner is here most days now.” The provider demonstrated their commitment to making improvements and told us, “This care home is my passion, I will not fail, there are too many people relying on me.”

We identified two continued breaches of the regulations because the provider had not ensured that there were sufficient numbers of staff to care for people safely or that the skill mix of staff was suitable to meet people’s needs. You can see what action we told the provider to take at the back of the full version of the report.

A registered manager was 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.

This was the first inspection since the new provider was registered in July 2015. The registered manager had been in post for five months at the time of the inspection. They told us that a number of changes had already been made and plans were in progress as part of an ongoing development programme. We identified a number of areas of practice that needed to improve and four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, relating to inadequate levels of staffing, lack of support at meal times, lack of person centred care and poor management oversight. You can see what action we asked the provider to take at the back of the full version of this report.

There were not always enough staff on duty to ensure that people’s needs were met. People, their relatives and staff told us that there were not enough staff and our observations confirmed this. Staff were rushing between tasks and they had little time to spend with people. People often had to wait for support with their care needs and some people did not receive the support they needed. We identified this as an area of practice that requires improvement.

People told us they enjoyed the food at Hilgay and that they could choose what they liked to eat. One person said “It’s usually nice, tasty food.” However some people were not supported effectively at meal time because staff were not always available to help them. One staff member said “We need more hands, especially at lunchtime.” We identified this as an area of practice that requires improvement.

Care plans and risk assessments did not reflect people’s individual needs and lacked detail and information to guide staff in how to care for people safely. Risks to people were not consistently managed. Some people had been identified as being at high risk of falls however there was no clear guidance for staff in how to provide care safely or how to manage the risks. This was identified as an area of practice that needs improvement.

Care plans were not updated when people’s needs changed. Staff told us that they did not often refer to the care plans as they were “Not very useful.” Care plans were written in a generic way and did not always provide personalised detail such as people’s interests, preferences or specific wishes. The registered manager planned to introduce a new format but these were not yet in place. People were not supported to follow their interests and many people told us they were bored and did not have enough to do. A staff member said, “We haven’t got the staff to do activities with people, we have no time to spend one to one with people, and people don’t get to go out.” This was identified as an area of practice that requires improvement.

People and staff expressed mixed views about the management of the home. One person said “They aim to provide a good service.” One staff member said, “It’s hard for them coming into a new team but I have found them to be supportive. I am 99% happy with the manager and the team.” Systems for monitoring the quality of care provided were not always effective. For example, where people’s needs had changed their care plan had not been amended to mitigate risks. There was no auditing system in place to monitor, analyse and review the effectiveness of care plans. We identified this as an area of practice that requires improvement.

People told us that staff were caring, one person said, “The staff are kind and make sure I am alright.” Although most of the interactions that we witnessed between staff and people were kind and caring, we also saw some exchanges that were less positive. A staff member was heard to speak sharply to a person who was living with dementia. Staff did not always respond to someone who was frequently calling out, this meant that other people were disturbed by the noise. This caused them to complain about the person, within their hearing, leading to a possible loss of self-esteem and dignity for the person who was living with dementia. However, staff had developed positive relationships with people they were caring for and we saw many examples of caring and compassionate support.

Staff said they had access to training and received regular supervision to support them in caring for people. Staff had undertaken a range of training in the past year including courses specific to the needs of people living at Hilgay such as dementia awareness and diabetes training. Staff were able to demonstrate a good understanding of the Mental Capacity Act 2005 (MCA) and they were effective in seeking people’s consent before providing care.

People and their relatives spoke highly of the staff and told us that they felt safe living at Hilgay. One person told us, “I definitely feel safe here, that’s the reason I’m living here.” Staff had a firm understanding of how to safeguard people from abuse. Recruitment procedures were robust and ensured that staff were suitable to work with people. People’s medicines were managed safely by staff who were trained and assessed as competent in the administration of medicines.

People told us they could access health care services when they needed to and that staff supported them with this. A relative said “They are very quick to contact the doctor and to tell us.” A health care professional told us that staff were knowledgeable about the needs of the people they were caring for, saying “The staff work well with us, they are able to tell us about the residents and they help people to carry out the exercise programmes that we give them.”

The registered manager had a firm understanding of their responsibilities with regard to notifying CQC of relevant events. A system was in place to record and respond to complaints about the service and the registered manager monitored incidents and accidents. Some audits had been undertaken to measure care delivery including, an infection control audit. An action plan identified tasks that needed to be undertaken and these were either completed or in progress. A recent external audit of medicines had been undertaken by a pharmacist and the registered manager was in the process of working through the action plan resulting from this audit. Both the provider and the registered manager were committed to developing the service to provide a more person centred experience for people living at Hilgay.